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Withdrawal Record Form
NWRB record of quarterly groundwater
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: 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. :
Conditional Water Permit No. : __________________
Name of Source :
Fax No/s. :
Water Permit No. : ________________
Amount of Water Granted (lps):
Purpose: ________________
Date Issued :
Location of Source :
NWRB Tag No. :
Latitude :
Longitude :
Measuring Device (Production Meter / Flow Meter) :
Brand :
Serial No. :
Is the Meter Tested?
Yes
No
Size :
Test Result:
Date Tested:_____________
Name and Address of Testing Laboratory:
M E T E R
(Every End
INITIAL
MONTH
(Cubic Meter)
Prepared by :
R E A D I N G
of the Month)
FINAL
(Cubic Meter)
CONSUMPTION
(Cubic Meter)
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
