Republic of the Philippines

Department of Health
CENTER FOR HEALTH DEVELOPMENT - I

Name of Facility: ___________________________________________________________________________

Complete Address: ___________________________________________________________________________
No. & Street Barangay
________________________________________________________________________
City/Municipality Province Region
Date:

Water Source Supply:

Level I & II: Dug Well Deep Well

Spring Shallow Well

Level III (Specify): ________________________

COMPLIANT
ITEM REMARKS
Yes No
I. QUALITY OF SOURCE WATER
1. Source is 25 meters away from source of contamination.

II. PROTECTION OF PRODUCT WATER

1. Purification Room;
a. Used as sleeping quarter
b. Directly connected to a toilet
c. Animals is kept
2. Display or storing or sale of other items (groceries, dry
goods, cosmetics, etc.) other than the RWS materials.
3. Empty containers and refilled containers placed in slated
platform with height of 20 cm.

III. WATER PURIFICATION PROCESS

1. Water processing constructed/installed as per approved
design and operation. No by-pass in any of the operations.
2. Parts of the equipment (cartridges, membranes, pumps,
etc.) used, replaced as per manufacturers’ requirements.
IV. FILLING AND CAPPING
1. Filler not located adjacent to windows or openings.
2. Rim of container when filling pointed directly to the water-
dispensing nozzle.
V. WASHING AND SANTIZING
1. Product water used for rinsing.

VI. STORAGE OF WATER

1. Steel Tanks:

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 COMPLIANT
ITEM REMARKS
Yes No
a. DOH-certified water steel tanks; made of non-toxic
materials, durable, corrosion-resistant, non absorbent,
smooth, easily cleaned surface.
b. Soldering joints per approved DOH materials and
procedure.
c. Provided with manhole/opening, drainpipe, vermin
proofed vent and inlet and outlet pipes.
2. Concrete Sumps, Tanks, and Reservoirs:
a. Tested for water tightness.
3. Container with refilled water stored in a separate
storage room.

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 COMPLIANT
ITEM REMARKS
Yes No
4. Storage of refilled water not beyond 24-hours
holding time.

VII. TRANSPORT OF PRODUCT WATER

1. Water in delivery vehicles maintained at 25°C-28°C
temperature and provided with shade for protection from
direct sunlight.
VIII. ROOM/FACILITY AREA ALLOCATION
1. Complied with the 25 square meter area allocation.
2. All doors and partitions made of see-through materials
(glass, DOH-approved plastic).
IX. CONSTRUCTION OF PREMISES
1. Floors:
a. Constructed of impervious, non-skid easily cleaned
materials.
b. Adequately graded and drained.
c. “Close-type” floor drain provided in store or selling
area.
2. Walls:
a. Internal surfaces – smooth, even, non-absorbent and
easily cleaned materials.
b. Painted or finished light with colored materials.
3. Ceilings: constructed of smooth, non-absorbent materials;
painted light color.
4. Doors: self-closing, tight fitting with smooth and
non-absorbent surfaces.
X. MAINTENANCE OF PREMISES
1. No alteration, renovation additional construction, in any of
the rooms/facility of the establishment.
2. No alteration, addition, deletion or any change in the water
purification process.
3. Defective or damaged receptacles, appliances, furniture or
equipment discarded and replaced or repaired as required.
4. Rooms and premises maintained in tidy condition and free
from accumulation of refuse and/or wet flooring.
XI. TOILET FACILITIES

XII. HANDWASHING FACILITIES

1. Adequate and clean handwashing facilities provided to
employees of refilling stations.
2. Provided with nailbrush, soap or hand cleaner/sanitizer
and hand dryer.
XIII. SANITARY PLUMBING
1. The plumbing system, water piping, connections, fittings
and hoses conveying water constructed, installed and
repaired with in accordance with the NPCP and the NBC

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 COMPLIANT
ITEM REMARKS
Yes No
(PD 1096).
2. Source water lines protected from contamination; no cross
connection.
3. All piping and fitting materials (metal and plastic)
DOH-certified/approved.
XIV. LIQUID WASTE MANAGEMENT
1. Separate primary wastewater treatment facilities
constructed for domestic waste and gray water.
2. Gray water from the purification process recycled and
reused.
3. Adequate drainage facilities provided in the premises.

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 COMPLIANT
ITEM REMARKS
Yes No
XV. SOLID WASTE MANAGEMENT
1. Refilling station provided with 2 receptacles in all rooms
and premises, one for biodegradable (green color lining bag)
and one for non-biodegradable (black color lining bag).
XVI. VERMIN CONTROL
1. Absence of mice, rats, flies, mosquitoes, roaches and
other vermin in the rooms and premises.
XVII. PERSONNEL REQUIREMENTS
1. Refilling station being managed by a plant manager/
supervisor who passed the 40-hour basic certification course
for water operators or a SE or a person who has completed
the entire required subject for the course.
2. All personnel of the establishment possess up-to-date
health certificates.
3. All personnel wear their HC in their working garment.
XVIII. MISCELLANEOUS

XIX. OTHERS

Recommending Approval:

JULIEN JOAN G. LUD-AYEN, MD, MPH

Head – Health Facilities and EOH Section

Approved by:

Chief, Regulations Licensing and Enforcement Div.

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