Republic of the Philippines

Department of Health
METRO MANILA CENTER FOR HEALTH DEVELOPMENT
Acacia Lane, Welfareville Compound, Mandaluyong City

REQUEST FOR PRE-REPAIR INSPECTION

DESCRIPTION OF EQUIPMENT/PROPERTY:

TYPE: BRAND/MODEL:
SERIAL NO.: PROPERTY NO.:
REQUISITION DATE: ACQUISITION COST:
DATE OF LAST REPAIR: NATURE OF LAST REPAIR:
LOCATION:

DEFECTS/COMPLAINTS:
Nature and Scope of Work to be Done:

Requested by:

Date

PRE-REPAIR:

FINDINGS:

PRE-INSPECTED BY:

EDEN EBAJO FIDES PANGANIBAN

Member Chairman Vice-Chairman
Property Inspector Property Inspector Property Inspector

FRANCES ROSELMA GAERLAN

Member Member
Property Inspector Date Property Inspector

POST REPAIR:
Job Order No. Date
Invoice No. Date
Amount per Job Order No.
Payable amount of:

FINDINGS:

POST-INSPECTED BY:

EDEN EBAJO
Member FIDES PANGANIBAN
Property Inspector Chairman Vice-Chairman
Property Inspector Property Inspector

FRANCES ROSELMA GAERLAN

Member Member
Property Inspector Property Inspector
 Appendix 65

WASTE MATERIALS REPORT

Entity Name : DOH-MMCHD Fund Cluster :

Place of Storage : Date :
ITEMS FOR DISPOSAL
Record of Sales
Item Quantity Unit Description Official Receipt
No. Date Amount
1
2
3
4
5
6
7

PAR/ICS TO:
PAR/ICS No:
AMOUNT:

Certified Correct : Disposal Approved :

REGINE MAE L. DIOPENES RODEL ALEGRE

A.O. V MSSD-CAO
Signature over Printed Name of Signature over Printed Name of Head of Agency/Entity
Supply and/or Property Custodian or his/her Authorized Representative

CERTIFICATE OF INSPECTION
I hereby certify that the property enumerated above was disposed of as follows:

Item ________ Destroyed

Item ________ Sold at private sale
Item ________ Sold at public auction
Item ________ Transferred without cost to

Certified Correct: Witness to Disposal:

Signature over Printed Name of Signature over Printed Name of

Inspection Officer Witness