DocuSign Envelope ID: B54F981B-7963-41DA-BC36-D5C7DA602951

Control No. _______________________________

MWO-AM-1.2-F1 Asset Assessment Form_Rev 1
(to be filled up by Asset Management Department)

ASSET ASSESSMENT FORM

Facility Name Balara Pumping Station Date 1/29/2024
Balara Pumping Station, Balara Filtration Compound, L. Wood St., Brgy. Pansol Old Balara, Quezon
Address
City
Scope ☐ Building and other Structures ☒ Equipment, Furniture, Fixtures ☐ Land ☐ Others: ___________
☐ Disposal/ Reversion ☒ Transfer ☐ Inspection/ Report ☐ Others: __________________________
Action
For transfer, provide location: San Juan PS, Pasig PS

Rationale Request for transfer of assets to Pasig PS, San Juan PS, and Pinugay Storage Facility

Material/ Equipment for Assessment (Attach annexes with references, Detailed Asset List, pictures, etc.)
Asset/ Equipment Code Qty. Description Remarks
-Will be used as critical spare part
WS-WPS-BAL-00365 3 pcs/set Power Fuse Holder -Turn-over at San Juan Stock coordinate with
Jon Pastoril

-Will be used as critical spare part

WS-WPS-BAL-00365 3 pcs/set Power Fuse -Turn-over at San Juan Stock coordinate with
Jon Pastoril

Allis-Chalmers Transformer Used as reliability projrct c/o Lee Diquatco and Loui John Gutierez,
WS-WPS-BAL-00091 1 set to be stored in Pasig PS for safe keeping

(4MVA, 34.4KV, 2.4KV, 962A)

WS-WPS-BAL-00090 3 pcs/set Current Transformer Used as reliability projrct c/o Lee Diquatco and Loui John Gutierez,
to be stored in Pasig PS for safe keeping

WS-WPS-BAL-00090 3pcs 2.4KV Bus Bar Used as reliability projrct c/o Lee Diquatco and Loui John Gutierez,
to be stored in Pasig PS for safe keeping

WS-WPS-BAL-00090 1 set Battery Charger Used as reliability projrct c/o Lee Diquatco and Loui John Gutierez,
to be stored in Pasig PS for safe keeping

1/29/2024
Jan 15, 2024
01/13/2024
Roygie T. Dolores|________ Neil Dominic Namoro|________ Cyrill John R. Arellano
_____________________|________
QC-Pumping Station Grid Manager Department Head MSD/Projects Representative
Reviewed by:
Submitted by:

Gabriel Estrada|________ Evangeline M. Clemente|________ Ermond Jacobo|________

SAMG Asset Manager SAMG Group Director FAA
What follows from this is for Disposal or Reversion Only
For disposal > PhP 10M, follow MWO Authority Limits. Kindly attach Minutes of Meeting or Inter-Office Memorandum to document approval
Reviewed by: Approved by: (for disposal <= PhP10M)

___________________________ _______________________________
Disposal Committee Head Group Director, Strategic Asset Management
For Asset Management Department Use (Ownership)
For Land, Building and other Structures For Equipment, Furniture, Fixtures
Ownership: Ownership:
☐ MWSS turned over ☐ MWCI-acquired ☐ MWSS turned over ☐ MWCI-acquired
Available documents: Available documents:
☐ MOA ☐ TCT ☐ DODA ☐ DOAS ☐ As-built Plans ☒ Project ☐ Detailed Asset List ref. No: ______________ ☐ ACR ☐ SAP
Documents ☐ Others: ______________________ ☐ JO/PO ☒ Others: ______________________
For Concession Investment Accounting Department Use (Writeoff)
Noted by: Approved by: Writeoff Reference No.:
_____________________
Date:
FIXED ASSETS ACCOUNTING HEAD CIA DEPARTMENT HEAD _________/_________/________
DocuSign Envelope ID: B54F981B-7963-41DA-BC36-D5C7DA602951

Current Transformer

2.4KV Bus Bar

Battery Charger

3 pcs Power Fuse Holder

Allis-Chalmers Transformer

3pcs / 1 set Power Fuse

DocuSign Envelope ID: B54F981B-7963-41DA-BC36-D5C7DA602951

Control No. _______________________________

MWO-AM-1.2-F1 Asset Assessment Form_Rev 1
(to be filled up by Asset Management Department)

ASSET ASSESSMENT FORM

Facility Name Balara Pumping Station Date 1/29/2024
Balara Pumping Station, Balara Filtration Compound, L. Wood St., Brgy. Pansol Old Balara, Quezon
Address
City
Scope ☐ Building and other Structures ☒ Equipment, Furniture, Fixtures ☐ Land ☐ Others: ___________
☒ Disposal/ Reversion ☐ Transfer ☐ Inspection/ Report ☐ Others: __________________________
Action
Pinugay
For transfer, provide location: San Juan PS,Facility
Pasig PS

Rationale Request
Request for for disposal/Storage
transfer toPS,
of assets to Pasig Pinugay
San JuanFacility
PS, and Pinugay Storage Facility

Material/ Equipment for Assessment (Attach annexes with references, Detailed Asset List, pictures, etc.)
Asset/ Equipment Code Qty. Description Remarks
WS-WPS-BAL-00090 3 pcs/set Lightning Arrester
WS-WPS-BAL-00365 3 pcs/set Fuse-cut out with holder
Transformer solid copper
WS-WPS-BAL-00090 3 pcs (terminal) H1, H2, H3
WS-WPS-BAL-00090 2 pcs Galvanized frame channel
WS-WPS-BAL-00090 2 pcs Galvanized crossarm
WS-WPS-BAL-00090 3 pcs Pin Insulator
WS-WPS-BAL-00090 6pcs/2sets Suspension Insulator
WS-WPS-BAL-00090 1 lot Machine Bolts
WS-WPS-BAL-00090 3 pcs Double Arming Bolt
WS-WPS-BAL-00090 6pcs/2sets Strain clamp u-bolt
WS-WPS-BAL-00090 6 pcs Pole Clamps
WS-WPS-BAL-00090 1 lot Bare copper
WS-WPS-BAL-00090 2 pcs 20 ft. Concrete posts
WS-WPS-BAL-00090 1 lot XLPE Power Cables
WS-WPS-BAL-00090 1 set MVSG (1200A, 2.4KV, 3PH, 60Hz)
WS-WPS-BAL-00090 2 pcs 12V Battery
TX Secondary to VCB 2.4KV XLPE
WS-WPS-BAL-00092 6 pcs Jumper Wire
WS-WPS-BAL-00090 1 lot Control Cable
WS-WPS-BAL-00090 1 set Cover Switchgear

Jan 15, 2024 1/29/24

01/13/2024
Roygie T. Dolores|________ Neil Dominic Namoro|________ Cyrill John R. Arellano
_____________________|________
QC-Pumping Station Grid Manager Department Head MSD/Projects Representative
Submitted by: Reviewed by:

Gabriel Estrada|________ Evangeline M. Clemente|________

____________________ Ermond Jacobo|________
SAMG Asset Manager SAMG Group Director FAA
What follows from this is for Disposal or Reversion Only
For disposal > PhP 10M, follow MWO Authority Limits. Kindly attach Minutes of Meeting or Inter-Office Memorandum to document approval
Reviewed by: Approved by: (for disposal <= PhP10M)

___________________________ _______________________________
Disposal Committee Head Group Director, Strategic Asset Management
For Asset Management Department Use (Ownership)
For Land, Building and other Structures For Equipment, Furniture, Fixtures
Ownership: Ownership:
☐ MWSS turned over ☐ MWCI-acquired ☐ MWSS turned over ☐ MWCI-acquired
Available documents: Available documents:
☐ MOA ☐ TCT ☐ DODA ☐ DOAS ☐ As-built Plans ☒ Project ☐ Detailed Asset List ref. No: ______________ ☐ ACR ☐ SAP
Documents ☐ Others: ______________________ ☐ JO/PO ☒ Others: ______________________
For Concession Investment Accounting Department Use (Writeoff)
Noted by: Approved by: Writeoff Reference No.:
_____________________
Date:
FIXED ASSETS ACCOUNTING HEAD CIA DEPARTMENT HEAD _________/_________/________
DocuSign Envelope ID: B54F981B-7963-41DA-BC36-D5C7DA602951

3pcs / 1 set Polymer Lightning Arrester

1 pc Fuse Cut-out with holder

2 pcs Galvanized Frame Channel 2 pcs Crossarm

Transformer solid copper & Bare Copper

Machine bolts

3 pcs Pin Insulator

DocuSign Envelope ID: B54F981B-7963-41DA-BC36-D5C7DA602951

12V Battery

MVSG

Control Cable

Concrete posts XLPE Cables

6 pcs Pole Clamp

Double arming bolts Strain Clamp U-bolt

6 pcs / 2 sets Suspension Insulator

DocuSign Envelope ID: B54F981B-7963-41DA-BC36-D5C7DA602951

Cover Switchgear

TX Secondary to VCB 2.4KV

XLPE Jumper Wire
Certificate Of Completion
Envelope Id: B54F981B796341DABC36D5C7DA602951 Status: Completed
Subject: Complete with DocuSign: FOR TRANSFER-Asset Transfer Form_BPS High Voltage.pdf, FOR DISPOSAL - A...
Source Envelope:
Document Pages: 6 Signatures: 6 Envelope Originator:
Certificate Pages: 5 Initials: 0 Gabriel Estrada
AutoNav: Enabled MWSS Administration Building
EnvelopeId Stamping: Enabled QUEZON CITY, MAN 1105 MAN 1105
Time Zone: (UTC+08:00) Taipei [email protected]
IP Address: 136.226.235.11

Record Tracking
Status: Original Holder: Gabriel Estrada Location: DocuSign
Feb 6, 2024 | 08:05 [email protected]

Signer Events Signature Timestamp

Ermond G. Jacobo Sent: Feb 6, 2024 | 08:25
[email protected] Resent: Feb 8, 2024 | 15:51
Security Level: Email, Account Authentication Resent: Feb 8, 2024 | 15:51
(None) Resent: Feb 12, 2024 | 08:24
Signature Adoption: Uploaded Signature Image
Resent: Feb 12, 2024 | 08:24
Using IP Address: 120.28.45.182
Viewed: Feb 14, 2024 | 08:52
Signed: Feb 14, 2024 | 08:52
Electronic Record and Signature Disclosure:
Accepted: Mar 22, 2022 | 07:58
ID: 782342c6-a0b9-4057-a7e9-af061a3483ed

Eva Clemente Sent: Feb 6, 2024 | 08:25

[email protected] Viewed: Feb 6, 2024 | 08:48
Security Level: Email, Account Authentication Signed: Feb 6, 2024 | 08:49
(None)
Signature Adoption: Uploaded Signature Image
Using IP Address: 120.28.45.182

Electronic Record and Signature Disclosure:

Accepted: Feb 6, 2024 | 08:48
ID: 17a60d16-3003-4d7f-af3d-57d95c259a37

Gabriel Estrada Sent: Feb 6, 2024 | 08:25

[email protected] Viewed: Feb 6, 2024 | 08:26
Security Level: Email, Account Authentication Signed: Feb 6, 2024 | 08:26
(None)
Signature Adoption: Uploaded Signature Image
Using IP Address: 122.52.254.242

Electronic Record and Signature Disclosure:

Accepted: Dec 5, 2021 | 11:53
ID: 80efa9fc-7e82-4017-896f-5cc58b5095f8

In Person Signer Events Signature Timestamp

Editor Delivery Events Status Timestamp

Agent Delivery Events Status Timestamp

Intermediary Delivery Events Status Timestamp

Certified Delivery Events Status Timestamp

Carbon Copy Events Status Timestamp

Witness Events Signature Timestamp

Notary Events Signature Timestamp

Envelope Summary Events Status Timestamps

Envelope Sent Hashed/Encrypted Feb 6, 2024 | 08:25
Certified Delivered Security Checked Feb 6, 2024 | 08:26
Signing Complete Security Checked Feb 6, 2024 | 08:26
Completed Security Checked Feb 14, 2024 | 08:52

Payment Events Status Timestamps

Electronic Record and Signature Disclosure
Electronic Record and Signature Disclosure created on: Feb 15, 2021 | 17:55
Parties agreed to: Ermond G. Jacobo, Eva Clemente, Gabriel Estrada

ELECTRONIC RECORD AND SIGNATURE DISCLOSURE

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