NWRB-MED-21-r0

NATIONAL WATER RESOURCES BOARD

8th Floor NIA Bldg., EDSA, Quezon City
Telefax No.:(02) 920-26-54
Website: nwrb.gov.ph

SUMMARY RECORD OF QUARTERLY GROUNDWATER /

SURFACEWATER WITHDRAWAL
PERIOD : ______________, _________ TO : ______________, _________
(Month) (Year) (Month) (Year)

Permittee/Grantee :
Mailing Address :
Contact Person : E-Mail Address :
Tel. No/s. : Mobile No. : Fax No/s. :

Conditional Water Permit No. : __________________ Water Permit No. : ________________ Purpose: ________________
Name of Source : Amount of Water Granted (lps): Date Issued :
Location of Source :
NWRB Tag No. : Latitude : Longitude :

Measuring Device (Production Meter / Flow Meter) :

Brand : Serial No. : Size :
Is the Meter Tested? Yes No Test Result: Date Tested:_____________
Name and Address of Testing Laboratory:

M E T E R R E A D I N G
(Every End of the Month)
MONTH INITIAL FINAL CONSUMPTION
(Cubic Meter) (Cubic Meter) (Cubic Meter)

Prepared by : Submitted by :

Signature Over Printed Name Signature Over Printed Name

Position Position

NOTE:
1. INSTALLED PRODUCTION METER MUST BE TESTED BY NWRB OR ITS AUTHORIZED TESTING LABORATORY.
2. ANY REPLACEMENT OF METER MUST BE REPORTED TO NWRB WITHIN FIVE (5) DAYS INDICATING THE FOLLOWING:
PRODUCTION METER SERIAL NO. READING DATE REPLACED
OLD
NEW
3. ALL RECORD OF MONTHLY WATER WITHDRAWALS PER SOURCE MUST BE SUBMITTED EVERY THREE (3) MONTHS BY THE PERMITTEE
TO : THE CHIEF, MONITORING AND ENFORCEMENT DIVISION
NATIONAL WATER RESOURCES BOARD

This form may be reproduced by the Permittee. Keep this record on file. MED FORM 2014