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DILG Form San Luis
DILG Form San Luis
Region: __X____________________________________________________________________
Province: __MIS. OR.____________________________________________________________
Municipality: __GINGOOG CITY____________________________________________________
Proponent Brgy.: BARANGAY SAN LUIS_______________________________________
Project Title: ___________________________________________________________________
Project Description: ______________________________________________________________
Estimated Project Cost: ___________________________________________________________
A. TECHNICAL REQUIREMENTS:
YES NO
B. NON-TECHNICAL REQUIREMENTS:
YES NO
IF NO: Change the location of the water supply structure affected (e.g location
tank [must be within the proponent barangay])
YES NO
IF NO: Ensure that engineering mitigation is included in the DED to counter the
identified hazard.
YES NO
IF NO: Include the estimated additional cost for the provision of electricity.
Evaluated by:
___________________________ ___________________________
Name and Position Name and Position
___________________________ ___________________________
Name and Position Name and Position
Approved by:
___________________________
DILG Provincial Director