DECLARATION FORM for INDUSTRIAL PREMISES / BORANG DEKLARASI bagi PREMIS PERINDUSTRIAN

TYPE OF INDUSTRY (JENIS PERINDUSTRIAN )

Please specity (Sila Nyatakan )

Example : Beverage, Chemical, Electrical, Electronic, Machinery & Equipment, Mineral, Paper, Petroleum, Plastic, Rubber, Textile, Tobacco, Wood or Others
(Contoh : Minuman, Kimia, Elektrik, Elektronik, Jentera & Peralatan, Logam, Kertas, Minyak, Plastik, Getah, Tekstil, Tembakau, Kayu-kayan atau Lain-lain )

Type of Products Manufactured (Jenis Produk Pembuatan )

Is your organisation registered with any Trade Associations? (Example: FMM, MICCI, etc). Please state here:
(Adakah organisasi anda didaftarkan dengan sebarang Persatuan Perdagangan? (Contoh: FMM, MICCI, dll). Sila nyatakan di sini ):

INDUSTRIAL WASTE / BUANGAN PERINDUSTRIAN

Does the industrial effluent from your factory flows into the sewerage system or septic tank? Yes No

Adakah cecair buangan perindustrian dari kilang anda mengalir ke dalam sistem pembetungan atau tangki septik? Ya Tidak

DOMESTIC WASTE / BUANGAN DOMESTIK

What kind of sewerage system does your factory have? (Apakah jenis sistem pembetungan yang terdapat di kilang anda?)

Septic Tank (Tangki Septik )

Connected Service (Perkhidmatan Bersambung )

Mechanical Sewerage Treatment System. Please specify type of system :-

(Sistem Rawatan Kumbahan Mekanikal. Sila nyatakan jenis sistem :-)

Others. Please specify (Lain-lain. Sila nyatakan )

Name of Desludging Contractor (Nama Kontraktor Pengosongan Tangki Septik / Sistem Pembetungan )

Contact Number of the Desludging Contractor (Nombor Telefon Kontraktor Pengosongan Tangki Septik / Sistem Pembetungan )

Frequency of Desludging (Kekerapan Pengosongan Dijalankan )

Sludge Disposal Address or Location (Alamat atau Lokasi Pembuangan Enapcemar )

Name, Address, Telephone & Fax Numbers of Branch Offices / Subsidiaries (Nama, Alamat, Nombor Telefon dan Faks Pejabat Cawangan / Anak Syarikat )

Remarks / Catatan

Please return this Declaration Form to (Sila kembalikan Borang Deklarasi ini kepada ): -

Via Mail (Melalui Pos) : JABATAN PELANGGAN, PENGEBILAN & PEMUNGUTAN, INDAH WATER KONSORTIUM SDN BHD (211763-P),

ARAS 5, NO.44 JALAN DUNGUN, DAMANSARA HEIGHTS, 50490 KUALA LUMPUR

Via Fax (Melalui Faks) : 03-2095 9005 / 03-2095 6002

Via E-Mail (Melalui E-mel) : care@iwk.com.my

Should you have further inquiries, please do not hesitate to contact us at 03-2083 2828 or SMS 63660 (type iwk<space>message)

Untuk sebarang pertanyaan, sila hubungi kami di talian 03-2083 2828 atau SMS 63660 (taip iwk<jarak>pesanan)

Doc No. : IWK/CBCD/DB/FO/06

Rev No. : 00
Effective Date: 04 Jan 2019
 DECLARATION FORM for INDUSTRIAL PREMISES / BORANG DEKLARASI bagi PREMIS PERINDUSTRIAN
Indah Water Sewerage Account Number
(Nombor Akaun Pembetungan Indah Water)
Name of Organisation
Nama Organisasi

Address of Factory/Premise
Alamat Kilang/Premis

Water Account Number(s) Monthly Average Water Usage (m3)

Nombor Akaun Air Purata Penggunaan Air Bulanan (m 3 )

Name of your Local Authority (Nama Pihak Berkuasa Tempatan anda )

Property Assessment Bill Account Number (Nombor Akaun Cukai Taksiran Bangunan )

DECLARATION FOR YEAR (DEKLARASI BAGI TAHUN )

Full Time Employees Part Time / Casual Employees

Pekerja Sepenuh Masa Pekerja Separuh Masa / Sementara
Month Total Employees
{ permanent and contract employees / { employees who work not less than 20 days a
Bulan pekerja sepenuh masa dan kontrak } month / pekerja yang bekerja tidak kurang Jumlah Pekerja
daripada 20 hari sebulan }

JANUARY (Januari )

FEBRUARY (Februari )
MARCH (Mac )

APRIL (April )
MAY (Mei )

JUNE (Jun )

TOTAL (Jumlah )
AVERAGE (Purata )
JULY (Julai )

AUGUST (Ogos )

SEPTEMBER (September )

OCTOBER (Oktober )
NOVEMBER (November )

DECEMBER (Disember )

TOTAL (Jumlah )
AVERAGE (Purata )
I/We hereby confirm that the above organisation is a manufacturing based industrial premise and the Total Employees Record declared in this Declaration Form is true. In
the event if the headcount is less than ten(10), we hereby agree to be billed as Industrial, based on a minimum headcount of ten(10) rather than Commercial charges.

Saya/Kami dengan ini mengesahkan bahawa nama organisasi yang tersebut di atas adalah sebuah premis pembuatan berasaskan perindustrian dan Jumlah Rekod Pekerja
yang tercatat di atas adalah benar . Sekiranya jumlah pekerja adalah kurang daripada sepuluh(10) orang, kami dengan in bersetuju dikenakan caj Perindustrian berasaskan
jumlah pekerja minimum seramai sepuluh (10) orang daripada dikenakan caj Komersil.

IMPORTANT : Please attach a copy of the Manufacturing/Industrial License from the Ministry of Trade and Industry (MITI) / Local Authority
PENTING : Sila lampirkan sesalinan Lesen Pengilangan daripada Kementerian Perdagangan dan Perindustrian Malaysia (MITI) / Pihak Berkuasa Tempatan

Declared by / Dideklarasi oleh; Company Stamp / Cop Syarikat

Signature / Tandatangan

Name / Name

Telephone Number (Nombor Telefon )

Designation / Jawatan
Fax Number (Nombor Faks )

Date / Tarikh

Doc No. : IWK/CBCD/DB/FO/06

Rev No. : 00
Effective Date: 04 Jan 2019