Cambodia - Rural Investment and Local Governance Project (Vol. 3 of 6) : Seila programme - commune & Sangkat infrastructure project information form

E671 vol. 3 Commune / Sangkat Infrastructure Project Seila Project Information Form Programme Province / Municipality |Commune /Sangkatl District GIS Code Part 1:General Information Name of Project Date Study Name of Technical Assistant Status of Technical Completed Assistant Objective of the Project Sector Type Proposed Outputs (From Commune / Proposed Outputs After Study Sangkat Development Plan) Estimated Cost In Plan Estimated Cost after Study Proposed year of implementation (from Commune / Sangkat Development Plan) Beneficiaries of Project Village Name Number of Users Number of Total Women Households Totals:  Commune / Sangkat Infrastructure Project Information 'W Seila Programme District Commune Project Name Date Part 2: Project Map  J14 Commune / Sangkat Infrastructure Project Information 4W Seila Programme Distnct Commune Project Name Date Part 3: Technical Information and Site Plans  Commune / Sangkat Infrastructure Project Information Seila Programme District Commune IProject Name Date Part 4: Local Resources and the environment 4.1 Are there any local resources which can be used in the construction of the project? 4.2 Will construction of the project cause any damage to any place that is important for environmental or cultural reasons (for example, forest, a wildlife park or a temple?) 4.3 Will construction of the project cause any damage to water supplies used by people? 4.4 l Is the output of the project a new road? f 4.5 Is the output of the project a new irrigation system? Note: If the answer to any of questions 4,1 to 4,4 is "yes", the Provincial Office of Local Administration should carry out an Environmental Impact Assessment.  Commune / Sangkat Infrastructure Project Information 4AM Seila Programme District Commune Project Name Date 5. Land Ownership What kind of land will the prolect be built on? Choose one answer. 1 Only on land that is public land and is not used for farming. 2 Some private land will be used. No landowner will have to give more than 5% of his land for the project. No private buildings or places of business will be moved or destroyed. 3 Some landowner will have to give more than 5 % of his land, or some private buildings or places of business will be moved or destroyed. Note: If answer (2) is chosen, the Commune or Sangkat Chief should prepare a report to show that the land owners have agreed to contribute their land for the project. If answer (3) is chosen, the Provincial / Municipal Office of Local Administration should prepare a Land Acquisition Report.  Commune / Sangkat Infrastructure Project Information Seila Programme District Commune Project Name Date 6. Summary of information 6.1 Is there any reason why this project may not be successful? Answer by Technical Assistant Check by P/M OLA 6.2 Has all the project study information been provided? Information Answer by Checked Technical by P/M Assistant OLA Objective Sector Proiect Tvpe Beneficiaries Project Map Technical Information (depending on project type Site Plans Technical Design Cost Estimation Operation and Maintenance Plan Natural Resources Environmental and Cultural Sites Land Ownership Does the project need a Land Acquisition Report? Does the project need an Environmental Impact Assessment? Signed By Commune / Sangkat Technical Assistant P / MOLA Chief Name Name Name Signature Signature Signature Date Date Date  1A.& Commune / Sangkat Infrastructure Project Information V Seila Programme District Commune Project Name Attachments 1. Site Plan Form 2. Project Outputs and Cost Estimates Form 3. Output Locations Form 4. Operation and Maintenance Plan Form  Commune / Sangkat Infrastructure Project Information Seila Programme Distnct Commune Project Name Date Village | Proposed OutputT GPS - X | GPS -Y Site Plan Soil Information Checklist of information to show on the From Depth To Depth Type of soil plan or rock Slope of the ground Depth biggest ever flood Normal Water in wet season Normal Water in dry season Direction of water flow Source of information Speed of water flow Who owns the land where the project will be built?  -LOLL Commune / Sang at Infrastructure Project Information fSeila Pogramme District Commune Project Name Date IT