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Q-2, r. 21 - Regulation respecting waterworks and sewer services

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FORM 3
(s. 41)
GOUVERNEMENT DU QUÉBEC
MINISTÈRE DU DÉVELOPPEMENT DURABLE, DE L’ENVIRONNEMENT ET DES PARCS
RATE ESTABLISHMENT OR MODIFICATION PROPOSAL
In accordance with sections 39 and 40 of the Regulation respecting waterworks and sewer services (chapter Q-2, r. 21) made under the Environment Quality Act (chapter Q-2), the undersigned applicant hereby informs the Minister of Sustainable Development, Environment and Parks that he (it) intends to establish or modify his (its) rates for the service he (it) provides and, for such purpose, submits the following information:
1. Name and address of the person, partnership, association, legal person or company operating the waterworks or sewer service:
Name: __________________________________________________________________________
Address: ________________________________________________________________________
2. (a) Nature of partnership, association, legal person or company:
_____________________________________________________________________________
(b) Type of service: waterworks __________ or sewer _________
3. Permit number ____________________
4. Name of the municipality (ies) served and number of subscribers in each municipality:
_______________________________________________________________________
| | | |
| | Designation | |
| Municipality | (city, town, village,)| Number of subscribers |
| | parish or township) | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
| | | |
|__________________|________________________|___________________________|
5. Annual tariffs in force and projected tariffs
(a) Table
________________________________________________________________________________
| | | | | |
| | | Tariffs | Projected | |
| Class | Number | in force | tariffs | Increase |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|House | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|1st faucet | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Additional faucets | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Bath | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Water-closets | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Hose | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Cooler | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Heating | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Automobile | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Hydrants | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Farmers | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Domestic animals | | | | |
|or | | | | |
|Stable | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Presbytery and church * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|School * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Convent * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|College * | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Hotel | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Store | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Commercial or industrial | | | | |
|establishments | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
| | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
| | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
|Miscellaneous (specify) | | | | |
|__________________________|___________|_____________|_____________|_____________|
| | | | | |
| *Immovables followed by an asterisk are not subject to rates in the case |
| where the operator of the system is a municipality. |
|________________________________________________________________________________|
N.B. If another tariff method is used, give details on a separate sheet.
(b) Date of collection of subscriptions:
____________________________________________________________________________
(c) Is the subscription payable in advance?
____________________________________________________________________________
(d) Is the service provided throughout the year or on a seasonal basis?
____________________________________________________________________________
6– Details on the actual cost of the system with all its accessories:

A– Supply: (stream, brook, spring or well) Actual cost
Spring or well............................. $________
Land and rights of way..................... $________
Catchment: (dam or basin).................. $________
Water intake............................... $________

B– Water treatment: Filtration................................. $________
Chlorination............................... $________
Building................................... $________
Other means................................ $________

C– Pumping: Pump....................................... $________
Motor...................................... $________
Building................................... $________

D– Reservoirs: ........................................... $________
........................................... $________

E– Canalization: (Branch pipe conduit and accessories or, in
the case of a sewer service, conduit for the
disposal of waste water)
........................................... $________
........................................... $________
........................................... $________

F– Distribution: (Conduits and accessories)
........................................... $________
........................................... $________
........................................... $________
........................................... $________
........................................... $________
........................................... $________
........................................... $________

G– Miscellaneous: (Contingencies, stock and general expenses):
........................................... $________
........................................... $________
TOTAL REAL COST: $________

P.S. If the above space is not sufficient, use a separate sheet and attach it
to your application.

7– A copy of the financial report submitted to the shareholders or partners at
their last annual meeting. In the absence of such report, it will be necessary
to provide a statement of the assets and liabilities and complete the table
hereunder.
________________________________________________________________________________
________________________________________________________________________________
|
INCOME | EXPENDITURES
_______________________________________|________________________________________
A– Receipts from service: | A– Operation and administration costs
| (Annex particulars)
|
Domestic.................... $________| Maintenance................. $________
|
Industrial.................. $________| Repairs..................... $________
|
Public...................... $________| Administration.............. $________
|
Special..................... $________| Discounts................... $________
|
.......................Total $________| Total $________
|
B – Others receipts: |B– Fixed expenses:
|
| Depreciation................ $________
$________|
| Interest.................... $________
|
| Taxes....................... $________
|
| Total: $________
Total: $________|
|
|
C – Additional revenue: |C– Unclassified expenditures:
|
$________| $________
|
$________| $________
|
Total revenue: $________| Total: $________
|
Annual surplus: $________| Total expenditures: $________
|
_______________________________________|________________________________________

Date: __________________ 20____
_______________________________________
Applicant
R.R.Q., 1981, c. Q-2, r. 7, Form 3.
© Gouvernement du Québec