Request Form

Certificate of Interconnection

Company Name: _______________________________________________________________________________

Address: ______________________________________________________________________________________
______________________________________________________________________________________
Laguna Water Contract Account Number: __________
LTI Locator since: ____ / _____ / _________ (mm/dd/yyyy)
Type of business: _______________________________________
Name of Company Representative: ___________________________________
Contact Number: _______________________________
Purpose: _______________________________________
To be filled up if tenant:
Company name of Lessor: _______________________________________________________________
Tenant since: ____ / _____ / _________ (mm/dd/yyyy)

______________________________
Signature

To be filled up by LAWC Business Area Team: To be filled up by LAWC Used Water Services Team:

Last 3 months’ average consumption: Sampling Date: _________________ (mm/dd/yyyy)

Industrial: _____________ cu.m. Remarks: _____________________________________
Domestic: _____________ cu.m. _____________________________________________
Average Monthly bill: Php _____________________ Dye Testing result: _____________________________
PUA: Php ________________________ Approved (Y/N): _______________________________

______________________________ ______________________________
Name and Signature Name and Signature
Territory Manager Facility Manager
Noted by:

_____________________________________
Business Zone Manager

LAGUNA AAAWATER CORPORATION

A Joint Venture of the Provincial Government of Laguna and Manila Water Company
2/F Banawe de Sta. Rosa Building, F. Reyes St., Balibago, Sta. Rosa City, Laguna 4026
Telephone Number: (049) 534 1627 · (02) 519 4887