APPLICATION FORM FOR COR#O10-016 APPLICATION FOR SECURING STANDARDS COMPLIANCE CERTIFICATE (SCC) (REFILLER/MARKETER /DEALER/RETAILER/HAULER/FACILITY) new [] renewal [| Business Name: Office Address/ Contact No.. Maes eo Eee OD netmer CD earteter 1] ose 1] necator Cater Facility for Registration: Refilling Plant ‘Auto-LPG Dispensing Station (storage tank/s capacity) (storage tank/s capacity) ‘Authorized LPG Brana/s Date Started of Operation: Location/Complete address of LPG establishment (1 application per activity/facility): Project Cost (pls. attach details) ‘Ownershi [1 inate Proprietorship: Name of Owner: [1 etme Partners: Corporation: ‘Authorized Representative/s: Address: Contact Details (including email address): Name and Signature of Applicant Before me, the undersigned authority, on this day personally appeared (name), of (name of company), known to me to be the person whose name is subscribed to the foregoing instrument, consisting of ___ attachments including this page ‘on which this acknowledgement is written, and upon his/her oath acknowledged to me that he/she executed the same for the purposes and consideration therein expressed and in the capacity therein stated. Given under my hand and seal of office this day of 201 NOTARY PUBLIC Doc. No. Page No. Book No. Series of.CHECKLIST OF REQUIREMENTS ‘OIMB/COR#010-SCCR FOR SECURING STANDARDS COMPLIANCE CERTIFICATE REFILLER (RMMscO) Documentary Requirements Remarks I. ‘Application Form T. Filled-up and notarized application form complete with the folowing information’ + Business name, address, telephone/ email adaress; * Location and complete adaress of LPG establisnmant/s; ‘+ Name of owner in case of single proprietorship, or partners in case of partnership, or authorized representative in case of corporation, ‘Supporting Documents Registration of Business from DTI or SEC ‘Mayor's/ Business Permit™ Fire Safety Inspection Certificate for Occupancy (Tor newly constructed factity)* Permit to Operate Untied Pressure Vessal from the Department of Labor and Employment (DOLE)* 'S. Supply Agreement* / Certification from SCC-holder supplier %. Certification on compliance with the Philippine National Standards (PNS) For Fefiling plant signed by designated responsible/authorized officer 7 Plant layout (no. of tanks, capacity, and other facilities) 8. List of trained and qualified personnel/servicemnen ‘Submit Certificate of “Teaining 3, List of clente/eustomers 10. List of vehicles (OR/CR, DOST Calibration Certificate for tank) Tt. ‘Supporting Documents for Renewal T._ Registration of Business from OT], if expired = Mayor's/ Business Permit, f expired™ '3._ Supply Agreement, ifexpired*/ Certification from supplier, new supplier Ww. ‘ORIGINAL COPY OF ABOVE DOCUMENTS™ TO BE PRESENTED FOR AUTHENTICATION PURPOSES. Corresponding Charges/Fees T. Acknowledgement of Notice/Engagement on the Dor (4 ume payment) » 500.00 2, SCC for LPG Establishments for 3 years (1 Issuance) » 3,000.00 43. SCC for LPG Establishments for 3 years (Renewal) 2,500.00 If Mailed: We only accept Postal Money Order (PMO) / Manager's Cheque (MC) payable to the Department of Eneray (DOE) Note: Processed by: Date: Noted by: All applications must be addressed to: Director, Oil Industry Management Bureau Department of Energy 3° Floor, PNOC Bldg. 5, Energy Center Rizal Drive, Bonifacio Global City, Taguig, NCR Tel Nos. 840-2130/840-2184/478-2900 Local 37.6CHECKLIST OF REQUIREMENTS FOR SECURING STANDARDS COMPLIANCE CERTIFICATE MARKETER (RMMScD) (OIMB/COR#011-SCCM Documentary Reaui ‘._ Application Form nts Remarke T. Filled-up and notarized application form complete with the following Information: ‘= Business name, address, telepnone/ email address; Location and complete address of LPG establishment/s; 2 Name of owner in case of single proprietorship, or partners in case of partnership, lf authorized representative in case of corporation, TE, Supporting Documents 1. Registration oF Business from DTI or SEC™ Registration of Brand from Intellectual Property Office (IPO)* 2 3. Mayor's/ Business Permit™ 4, Fire Safety Inspection Certificate for Occupancy (For newly constructed Faciity)™ 5. Refilling Agreement with SCC-holder supplier* (if without refilling facility) 6. List of qualified servicemen Submit Certinicate of Training 7, Names and addresses of authorized dealers/retall outlets 1. List of Vehicles used for the LPG business (model, make, plate number) TET, Supporting Documents for Renewal 1L._Registration of Business from DT, if expired™ 2, Mayor's) Business Permit, if expired™ 3._Refiling Agreement/ Certificate from SCC-holder supplier TV, ORIGINAL COPY OF ABOVE DOCUMENTS* TO BE PRESENTED FOR AUTHENTICATION PURPOSES V. Corresponding Charges/Fees 1. Acknowledgement of Notice/Engagement on the DO (time payment) * 500.00 2. SCC for LPG Establishments for 3 years (1+ Issuance) 3,000.00 3. SCC for LPG Establishments for 3 years (Renewal) 2,500.00 If Malled: We only accept Postal Money Order (PMO) / Manager's Cheque (MC) payable to the Department of Energy (DOE) Processed by: Date: Noted by: Note: All applications must be addressed to: Director, Oil Industry Management Bureau Departnent of Energy. 3° Floor, PNOC Bldg. 5, Energy Center Rizal Drive, Bonifacio Global City, Taguig, NCR ‘Tol Nos. 840-21 30/840-2184/479-2900 Local 376CHECKLIST OF REQUIREMENTS FOR SECURING STANDARDS COMPLIANCE CERTIFICATE DEALER (RMMSCD) OIMB/COR#012-SCCD Documentary Requirement Remarks, Application Form T, Filled-up and notarized application form (1 application per branch) complete with the following information: + Business name, address, telephone/ email address; 1 Location and complete addrass of LPG establishment/s) + Name of owner in case of single proprietorship, or partners in case of partnership, fr authorized representative in case of corporation TZ, Supporting Documents 1L._ Registration of Business from DTI or SEC* 2._Mayor's/ Business Permit '3._Fire Safety Inspection Certificate for Occupancy (for newly constructed facilty)™ “4. Certificate from SCC-holder refiler/marketer Submit 5. Uist of qualified servicemen coronate Training G._Names and addresses of authorized retailers 77._List of Vehicles used for the LPG business (model, make, plate number) TIT, Supporting Documents for Renewal 1L._ Registration of Business from DT, if expired 2. Mayor's/ Business Permit, if expired 3. Certificate from SCC-holder refiller/marketer, If expired IV. ORIGINAL COPIES OF ABOVE DOCUMENTS* TO BE PRESENTED FOR AUTHENTICATION PURPOSES. Corresponding Charges/Fees 7. Acknowledgement of Notice/Engagement on the DOT (@ time payment) : 500,00 2. SCC for LPG Establishments for 3 years (1* Issuance) 3,000.00, 3. SCC for LPG Establishments for 3 years (Renewal) 2,500.00, If Mailed: We only accept Postal Money Order (PMO) / Manager's Cheque (MC) payable to the Department of Energy (DOE) Note: Processed by: Date Noted by: All applications must be addressad to: Director, Oil Industry Management Bureau Department of Energy 3" Foor, PNOC Bldg. 5, Energy Center Rizal Drive, Bonifacio Global City, Taguig, NCR Tel Nos. 840-2130/840-2184/478-2800 Local 376,ommB/COR#013-SCCO CHECKLIST OF REQUIREMENTS FOR SECURING STANDARDS COMPLIANCE CERTIFICATE RETAIL OUTLET (RMMSCD) Documentary Requirements ‘X._Application Form T. Filled-up and notarized application form complete with the fellowing Information: + Business name, address, telephone/ email address; * Location and complete address of LPG establishment/s; + Name of owner in case of single propriatorship, or partners in case of partnership, or authorized representative in case of corporation, ‘T._Supporting Documents 1, Registration of Business from DTI* 2. Mayor's/ Business Permit 3, Fire Safety Inspection Certificate for Occupancy “4, Certification from SCC-holder supplier '. List of Vehicles used for the LPG business (model, make, plate number) TET. Supporting Documents for Renewal 1. Registration of Business from DTI or SEC 2. Mayor's/ Business Permit '3._ Supply contract/dealer's agreement, If previous is expired IV. ORIGINAL COPIES OF ABOVE DOCUMENTS TO BE PRESENTED FOR AUTHENTICATION PURPOSES: Z \V. Corresponding Charges/Fees Z. Acknowledgement of Notice/Engagement on the DOT (2 time payment) 500.00 2. SCC for LPG Establishments for 3 years (1** Issuance) ® 3,000.00 3. SCC for LPG Establishments for 3 years (Renewal) : 2,500.00 If Mailed: We only accept Postal Money Order (PMO) / Manager's Cheque (MC) payable to the Department of Energy (DOE) Processed by: Date: Noted by: Note: All applications must be addressed to: Director, Oil Industry Management Bureau Department of Energy 3° Floor, PNOC Bldg. 5, Energy Center Rizal Drive, Bonifacio Global City, Taguig, NCR Tel Nos. 840-2130/840-2184/475-2900 Local 376OIMB/COR#014-SCCA CHECKLIST OF REQUIREMENTS FOR SECURING STANDARDS COMPLIANCE CERTIFICATE ‘AUTO-LPG DISPENSING STATION (RMMSCD) Documentary Requirements Remarks, Application Form T, Filed-up and notarized application form complete with the following information ‘= Business name, address, telephone/ email address + Location and complete address of LPG establishment/s {+ Name of owner in case of single proprietorship, or partners in case of partnership, or authorized representative in case of corporation 1. Supporting Documents Registration of Business from DTI or SEC* . Mayor's/ Business Permit }. Fire Safety Inspection Certificate for Occupancy (for newly constructed faciity)* Certification from SCC-holder supplier Engineering layout plan | ||] Certification on compliance with the Philippine National Standards (PNS) for ‘auto-LPG dispensing station signed by designated responsible/authorized officer List of auto LPG station personnel and proof of training and qualification List of dispensers, storage tanks, and bullet trucks/lorries with their corresponding ‘Certificate of Approval, or any other similar document as provided by the ‘equipment supplier/manufacturer 9, Latest photographs (in SR size) showing the full/ront, Flight, and left side views including price display boards, safety informational signs, among others HE. Supporting Documents for Renewal 1. Registration of Business from DTI or SEG, If expired® 2. Mayors/ Business Perm, expired? 3. Certificate from SCC-holder importer, f expired IV. ORIGINAL COPY OF ABOVE DOCUMENTS= TO BE PRESENTED FOR AUTHENTICATION PURPOSES V._ Corresponding Charges/Fees i. Acknowledgement of Notice/Engagament on the DO! (1 time) 500.00 2. ‘SCC for LPG Establishments for 3 years (1° Issuance) 3,000.00 3. SCC for LPG Establishments for 3 years (Renewal) 2,500.00, If Mailed: We only accept Postal Money Order (PMO) / Manager’s Cheque (MC) payable to the Department of Energy (DOE) Processed by: Date: Noted by: Note: Al applications must be addressed to: Director, Oil Industry Management Bureau Department of Energy 3 Floor, PNOC Bldg. 5, Energy Center Rizal Drive, Bonifacio Global Cty, Taguig, NCR Tel Nos. 840-2130/840-2184/479-2900 Local 376OIMB/COR#015-SCCG CHECKLIST OF REQUIREMENTS. FOR SECURING CERTIFICATE OF NON-COVERAGE GARAGE-BASED AUTO-LPG (RMMSCD) + Business name, address, telephone/ email address ‘+ Location and complete address of LPG establishment/s + Name of owner in case of single proprietorship, or partners in case of partnership, ‘or authorized representative in case of corporation 1, Supporting Documents for 1 Issuance and Renewal = _LTO/LTFRB Confirmation of at least thirty (30) taxi units in operation +” Certification issued by the applicant that: © they do not render retailing services © thelr dispenser does not have money wheels or price indicators thelr facilities shall not be open for retail to the motoring public > _ Certification issued by SCC-holder supplier/s THT. Corresponding Charges/Fees 1. Acknowledgement of Notice/Engagement on the DOT (1 time payment) > 500.00 2. CNC for LPG Establishments for 3 years (1** Issuance) 3,000.00, 3. CNC for LPG Establishments for 3 years (Renewal) 2,500.00, If Mailed: We only accept Postal Money Order (PMO) / Manager's Cheque (MC) payable to the Department of Energy (DOE) Processed by: Date: Noted by: Note: {All applications must be addressed to: Director, Oi Industry Management Bureau Department of Energy. 3° Floor, PNOC Bldg. 5, Energy Center Rizal Drive, Bonifacio Global City, Taguig, NCR Tel Nos, 840-2130/840-2184/479-2800 Local 376CHECKLIST OF REQUIREMENTS FOR SECURING STANDARDS COMPLIANCE CERTIFICATE LPG HAULER (RMMSCD) O1MB/COR#016-SCCH Documentary R ements Application Form Remarke T.Filled-up and notarized application form complete with the following Information + Business name, address, telephone/ email address * Address of LPG trucks garage + Name of owner in case of single proprietorship, or partners in case of partnership, or authorized representative in case of corporation |i, Application Form Supporting Documents 1, Registration of Business from DTI or SEC 2. Mayor's/ Business Permit™ 3. Convey mit from Bureau of Fire Protecion (BFP)™ “i. List of LPG trucks for the transport of bulk LPG (make/model, capacity, ‘OR/CR, plate no. and DOST Calibration Certificate of each) 2. Listing of delivery trucks/vehicies for the transport of LPG in cylinders (make/model, capacity, OR/CR, plate no.) 32. Supporting Documents for Renewal 1, Registration of Business from OTI or SEC, # expired™ 2. Mayor's/ Business Permit, if expired™ ‘3. Hauling contract, if previous is expired™ 3V. ORIGINAL COPY OF ABOVE DOCUMENTS* TO BE PRESENTED FOR AUTHENTICATION PURPOSES V.__ Corresponding Charges/Fees 1. Acknowledgement of Notice/Engagement on (1 time payment) 500.00 2. SCC for LPG Establishments for 3 years (1" Issuance) 3,000.00, 3. SCC for LPG Establishments for 3 years (Renewal) 2,500.00 If Mailed: We only accept Postal Money Order (PMO) / Manager's Cheque (MC) payable to the Department of Eneray (DOE) Processed by: Date: Noted by: Note: All applications must be addressed to: Director, Oil Industry Management Bureau Department of Energy 3 Floor, PNOC Bldg. 5, Energy Center Rizal Drive, Bonifacio Global City, Taguig, NCR Tel Nos. 840-21 30/840-2184/479-2900 Local 376