Form QT 1

P.U. (A) 36
Page 1 of 2

SIXTH SCHEDULE
[Subrule10(1)]

WATER SERVICES INDUSTRY ACT 2006

WATER SERVICES INDUSTRY (WATER RETICULATION AND PLUMBING) RULES 2014

APPLICATION FOR TEST AND INSPECTION OF

EXTERNAL WATER RETICULATION SYSTEM / SUPPLY MAIN*
(For Demand <50,000 liter per day / ≥50,000 liter per day*)

Date :

To : Pengurusan Air Selangor Sdn Bhd.

Address :
File No. :
Development
:
Title

I/We refer to the approval of plans, designs and specifications for the implementation of an
external water reticulation system/supply main* for the above named development as
notified by SuruhanjayaPerkhidmatan Air Negara on …………………………….

2. In accordance with rule 10 and the Sixth Schedule of the Water Services Industry
(Water Reticulation and Plumbing) Rules 2014, I/We hereby apply for [material and pipe
inspections, for pressure and leakage tests/for supervision of tapping connection, for
sterilization, dewatering, flushing and water quality testing activities/for inspection, testing
and commissioning of mechanical and electrical works/and final inspection for handover of
facilities to the water distribution licensee],* and we submit herewith a cheque for the sum of
RM……………………… payable to ……………………………..(name of water distribution
licensee) for …………………………….(name of water distribution licensee) to conduct the
said inspections, supervisions and tests.

3. Notification shall be issued to your office when preparations to carry out the aforesaid
inspection, supervisions and tests have been completed.

……..……………………………..

Signature of Consultant
 Form QT 1
File No. : P.U. (A) 36
Page 2 of 2

Name of Consultant (in capital letters):

NRIC no. :
Address :
QP no :
Designation :
Date :

(*Delete whichever is not applicable)