Ver. 2014.11.

05

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Water Service Provider
LISTAHANG TUBIG Survey Form
Do not leave any question blank. Write “N.A.” if data is not available or not applicable.
Refer to accompanying instructions when filling out this form.
Water Service Provider Data
1
Management Type BWSA LGU-Run Utility Industrial Locator
RWSA Water District Peddler
Cooperative Real Estate Developer Ship Chandler
Homeowners’ Association Unnamed Water Service Provider Other Private Operator
2
Water Service Provider Name 3
Year started 4
Do you have internet access?
(If you are an unnamed water service provider, use your purok/sitio and barangay as operation
your name.)  Yes No

5 Level of Service  Level 1 only  Level 2 only  Level 3 only

 Mix of Levels 1 and 2  Mix of Levels 2 and 3
Water Service Provider Address
6
Region 7
Province 8
City/Municipality 9
Barangay

10
Street Address (Please do not use a P.O. address.)

Contact Person Data

The Contact Person should be the person who will be contacted if there is a need to clarify data provided.
11
Contact Person Name 12
Email Address
13
Telephone Number 14
Mobile Number 15
Fax Number

Service Area and Households Served in 2017

Use additional page if necessary
No. 16
Region 17
Province 18
City/Municipality 19
Barangay 20
Households Served
1
2
3
4
5

Volume of Water Extracted in 2017

Fill out as much data in this section as possible. Use additional page if necessary
21
Water 22
Location and 24
Condition of With25 26
Average Daily
No.
Source 23
Geographical Coordinates Water Source Production Meter? Volume Extracted, m3
22
 Deep well Location  Yes  No
 Operational
 Spring
23
1  Surface Geographical Coordinates If no:
Latitude Longitude Altitude
 Not
 Bulk Water  Volume known
operational
 Rain Water O
____ ____’____” N ____O____’____” E m  Volume unknown
22
 Deep well Location  Yes  No
 Operational
 Spring
23
2  Surface Geographical Coordinates If no:
Latitude Longitude Altitude
 Not
 Bulk Water  Volume known
operational
 Rain Water O
____ ____’____” N ____O____’____” E m  Volume unknown

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 Ver. 2014.11.05

Water Service Provider Name

THE SECTIONS BELOW ARE TO BE FILLED UP BY LEVEL 3 OR MIX OF LEVELS 2 & 3 WSPS ONLY.
Technical Data for 2017
27
Percent of Service Area that are Poor 28
Average Persons Per Household

29
Total Number of Connections 30
Ave. Consumption /Connection/Month, m3 31
Total Employees

32
Volume Produced for the Year, m3 33
Bulk Water Purchased for the Year, m3 34
Volume Billed for the Year, m3

35
Hours of Service per Day 36
Minimum Water Pressure, psi 37
Do you regularly conduct potability test?
 Yes No
If yes, attach Certificate of Potability.
Financial Data for 2017
Income Statement Balance Sheet
38
Total Operating Revenues 43
Accounts Receivable
39
Total Operating Expenses 44
Total Current Assets
40
Depreciation Expense 45
Total Assets
41
Interest Expense 46
Total Current Liabilities
42
Net Income for the Year 47
Total Equity
48
50
Source of Financial Data Principal Repayment Due
Audited financial statements
for the Year
49
Interest on Loans Due
Unaudited financial statements
for the Year
Other Data
51
Are you operating for profit?  Yes No
52
Do you have plans to expand your existing service area?  Yes No

If you are a community based organization (water cooperative, BWSA, RWSA or Homeowners’ Association),
53
Are your consumers required to be members of your water utility?  Yes No
54
How many percent of your total consumers are members of your utility?  50% or less  Over 50%

Remarks
Use this section for additional information.

Thank you for sharing your data.

You may proceed to encode your data at Listahang Tubig website http://listahangtubig.cloudapp.net
or submit this form to your Municipal Planning and Development Coordinator.

You may register to upload your data at http://listahangtubig.cloudapp.net

 Ver. 2014.11.05

Water Service Provider

LISTAHANG TUBIG Survey Form
Instructions

1. This survey applies to a water service provider that provides the water requirements of a community of at least 15 households.
2. Fill up this form in 2 copies. Keep Copy 1 of the completed form for your files. Submit Copy 2 to your Municipal/City Planning and
Development Coordinator if you are not able to encode the contents of this form in the ListahangTubig website.
3. Use data for the calendar year ended December 31, 2017.

Water Service Provider Data Section

Box 1. Management Type
Box 2. Water Service
Provider Name
Box 3. Year Started
Operations
Box 4. Internet Access
Refer to these definitions.
 BWSA Non-stock, non-profit organizations envisioned to operate and manage Level I water
supply facilities.
 RWSA Community-based water user’s association formed to manage piped water supply
systems either with house connections (level 3) or a network of public taps (Level 2).
 Cooperative A membership organization formed under the Cooperative Code of the Philippines to
operate and maintain water supply systems and registered with the Cooperative
Development Authority.
 Homeowners’ An organization that operates and maintains a water supply system and is registered
Association with the Securities and Exchange Commission or Housing and Land Use Regulatory
Board.
 LGU-Run Utility A water supply system owned and operated by the provincial, city or municipal
government.
 Water District A quasi-public corporation formed by the local government unit under the Provincial
Water Utilities Act for the operation and maintenance of water supply and wastewater
management system, which has been issued a Certificate of Conditional Conformance
by the Local Water Utilities Administration.
 Real Estate A real estate developer operating the water supply system that provides potable water
Developer to lot owners within its real estate development.
 Unnamed water An unnamed water service provider is one that serves at least 15 households and
service provider which is not registered formally with any government agency.
 Industrial Locator An industrial estate operating the water supply system in an economic special zone to
provide water to its locators.
 Peddler Non-pipe water service provider operator extracting water and supplying/delivering
water by container.
 Ship Chandler A water supply operator providing water to ships.
 Other Private Sole proprietorships, corporations and other private entities formed under the general
Operator business and corporation laws of the country for the operation and maintenance of
water supply systems.
Use the official name of the water service provider.
If the water service provider is unnamed, indicate the sitio and barangay where the system is located.
This refers to the year the water service provider started operations.
Check the “yes” box if the water utility has internet access and can encode the Basic Water Service Provider Data
Form in the ListahangTubig website. Check the “no” box if the water utility cannot encode the data by itself.

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 Ver. 2014.11.05

Box 5. Level of Service Refer to these definitions.

 Level 1 only Point source
A protected well or a developed spring with an outlet but without a distribution system
as it is generally adaptable for rural areas where the houses are thinly scattered serving
an average of 15 households with people having to fetch water from up to 250 meters
distance
 Level 2 only Communal faucet system or stand post
A system composed of a source, a reservoir, a piped distribution network, and
communal faucets. Usually, one faucet serves 4 to 6 households. Generally suitable for
rural and urban fringe areas where houses are clustered densely to justify a simple
piped system
 Level 3 only Waterworks system or individual house connections
A system with a source, a reservoir, a piped distribution network and household taps. It
is generally suited for densely populated urban areas.
 Levels 1 and 2 Levels 1 and 2 systems co-existing in the service area with predominance of Level 2.
 Levels 2 and 3 Levels 2 and 3 systems co-existing in the service area with predominance of Level 3.

Water Service Provider Address Section

Box 6. Region Region where the water service provider is located
Box 7. Province Province where the water service provider is located
Box 8. City/Municipality City or municipality where the water service provider is located
Box 9. Barangay Barangay where the water service provider is located
Box 10. Street Address Mailing address of the water service provider. This will be useful should there be a need to visit the water service
provider office. Do not use a post office box number.

Contact Person Data Section

Box 11. Contact Person
Name
Box 12. Email Address
Box 13. Telephone Number
Box 14. Mobile Number
Box 15. Fax Number
This should be the name of the person who will be contacted should a follow up on data provided will be needed.
Provide the contact person’s email address, if any.
Communication will be faster if the Contact Person has an email address. If he does not have one yet, it is strongly
recommended that he create an email account. If no email address can be provided, indicate “none” in this box.
Provide the contact person’s landline.
Provide the contact person’s mobile number.
Provide the contact person’s fax number.

Service Area and Population Served Section

The water service provider may be serving more than one barangay. In such a case, fill up one line for each barangay covered and the
corresponding households that the water service provider is serving. If the water service provider is serving just a portion of the barangay, just fill
up the name of the barangay and the number of households served.

Add a separate sheet if there are more barangays served.

Box 16. Region These refer to the region or province city or municipality where the service area of the water service provider is
Box 17. Province located. For succeeding rows, if the barangays covered by the water service provider still belong to the same region
Box 18. City/Municipality or province or city/municipality of the previous line, just enter “same” under the appropriate columns.

Box 19. Barangay If there is more than one barangay covered, fill up as many lines as there are barangays covered, and indicate the
Box 20. Households Served corresponding households served.
If all the barangays in the LGU are served, just write under Barangay column “all” and give just one figure for the
total households served.

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Volume of Water Extracted Section
The water service provider may have more than one water source. Fill up all the requested information for each water source across the row.
Box 21. Water Source –
Bulk Water
Water Source –
Rain Water
Box 22. Location
Box 23. Geographical
Coordinates
Box 24. Condition of Water
Source
Box 25. Production Meter
Box 26. Ave. Daily Volume
Extracted, m3
Technical Data Section
All data should be for calendar year 2013.
Box 27. Percent of Service
Area that are Poor
Box 28. Average Persons per
Household
Box 29. Total Number of
Connections
Box 30. Ave. Consumption
per Connection per
Month, m3
Box 31. Total Employees
Box 32. Volume Produced
for the Year, m3
Box 33. Bulk Water
Purchased for the
Year, m3
Box 34. Volume Billed for
the Year, m3
Box 35. Hours of Service
Box 36. Minimum Water
Pressure, psi
Box 37. Potability of Water
Ver. 2014.11.05
Bulk water source refers to raw water or treated water purchased by the water service provider for distribution to
its customers. This water source may be purchased from another water service provider or from a company
producing water for sale to another water service provider.
Rain water harvesting refers to accumulating and storing rainwater for reuse for basic water needs.
Indicate the exact location of the water source. If this is not known, indicate the sitio or purok and barangay.
With the help of a GPS equipment or a smart phone with the appropriate application, get the latitude and
longitude coordinates of each water source including its altitude.
Check the appropriate box for the condition of the water source, if it is “operational or “not operational”.
Check the appropriate box if the water source has a production meter attached to it.
If there is no production meter, the volume extracted may still be known by other means. For Level 1, estimate the
number of containers used (drum, pail, etc.) and transpose it to cu.m. Check the appropriate box if volume is
known or not known.
Calculate the average volume of water (in cubic meters) that is extracted from each source daily.
Provide the % of population that are poor in your service area.
Provide the average number of persons per household in your service area.
Provide the total number of connections in your service area.
Provide the average consumption per connection per month, m3 in your service area.
Provide the total number of employees in your utility. Include both regular and contractual employees.
Provide the total volume of water produced for the year (in m3) coming from all water sources, like deep wells,
springs and surface water. Do not include bulk water purchases which is asked separately in Box 33. Correlate this
with the DAILY volume extracted from each water source asked in Question 26.
Provide the total volume of bulk water purchases for the year, m3. This should not exceed the declared average
daily volume of bulk water purchased (Question 26) when multiplied by 365 days.
Provide the total volume of water billed for the year, m3. Correlate this with the Average Consumption per
Connection per Month (Question 16).
Provide the number of hours of service per day by your utility.
Provide the minimum water pressure, in pounds per square inch (psi), based on your utility’s experience.
Indicate if your utility regularly conducts a potability test. If yes, attach the Certificate of Potability.
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 Ver. 2014.11.05

Financial Data Section

All data should be from financial statements for the calendar year 2013, preferably audited.

Box 38. Total Operating
Revenues
Box 39. Total Operating
Expenses
Box 40. Depreciation
Expense
Box 41. Interest Expense
Box 42. Net Income for the
Year
Box 43. Accounts Receivable
Box 44. Total Current Assets
Box 45. Total Assets
Box 46. Total Current
Liabilities
Box 47. Total Equity
Box 48. Principal
Repayment Due for
the Year
Box 49. Interest on Loans
Due for the year
Box 50. Source of Financial
Data
Indicate the total annual operating revenues from the Income Statement.
Indicate the annual total operating expenses from the Income Statement. This should NOT INCLUDE depreciation
and interest expense, which are shown separately.
Indicate the depreciation expense from the Income Statement.
Indicate the interest expense from the Income Statement, if any.
Indicate the net income for the year from the Income Statement.
Indicate the total accounts receivable from the Balance Sheet.
Indicate the total current assets from the Balance Sheet.
Indicate the total assets from the Balance Sheet.
Indicate the total current liabilities from the Balance Sheet.
Indicate total equity from the Balance Sheet.
Indicate principal repayments due in 2013, if any. If none, write “0”.
Indicate the amount of interest on loans that are due to be paid in 2013, if any. If none, write “0”.
Check the appropriate box if the financial data came from audited financial statements or not.

Other Data Section

Box 51. Are you operating for profit? Indicate if your utility is operating for profit by ticking the Yes or No box.
Box 52. Do you have plans to expand Check the appropriate box on plans to expand your existing service area.
your existing service area?
Answer questions 38 and 39 if you are a community based organization.
A community based organization is a water cooperative, a BWSA, a RWSA or a Homeowners’ Association.
Box 53. Are your consumers Check the appropriate box if your consumers are required to be members of your organization.
required to be members of
your water utility?
Box 54. Consumers that are Indicate the percentage of consumers that are members of the community-based organization.
members of your
organization

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