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Annex F Dealer

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60 views2 pages

Annex F Dealer

Uploaded by

regascodongalo2024
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Republic of the Philippines

DEPARTMENT OF ENERGY
Annex F
September 2022

Application for Issuance of License to Operate


LPG Dealer

Date__________________

Oil Industry Management Bureau / Field Office


Address

Attention: __________________
Director

Dear Sir/Madam:

In compliance with the Department Circular No. __________________, please be informed of this
application with details as follows:

A. Company Details

1. Company Name :
2. Business Address
(Number, Street, Brgy, Mun/City, Province & Region) :
3. GPS Coordinates (longitude & latitude) :
4. Telephone Number :
5. Email Address :

B. Establishment Details

1. Establishment Business Name :


2. Business Address
(Number, Street, Brgy, Mun/City, Province & Region) :
3. GPS Coordinates (longitude & latitude) :
4. Telephone Number :
5. Email Address :

C. Application Details

1. Type of application : Original ( ) Renewal ( )

D. Supporting Documentary Requirements

Please refer to the documentary requirements in Annexes F-1 to F-4 for compliance.

E. Compliance to Standards

The LPG product, Ancillary equipment, actual construction of an LPG facility and code of safety
practice shall comply with Annex J - List of reference standards/codes based on the latest
promulgated PNS or in the absence thereof any internationally accepted codes or standards.

Please refer likewise to the Dealer Outlet Layout Design in Annex F-5 and Price Display Board
Template in Annex K for compliance.

Energy Center, Rizal Drive cor. 34th Street, Bonifacio Global City, Taguig City, Philippines
1632 Tel. No. (Trunkline) (632) 8479-2900;
Website: http://www.doe.gov.ph; E-mail: [email protected]
Very truly yours,

____________________________________
Name, designation & signature of applicant
or authorized representative

Reminders/ Instructions:

1. This application shall be made per company and/or per establishment - facility, plant or outlet;
2. Submit this application form with complete documentary attachments to OIMB/FO for the issuance of the required License to
operate (LTO) before the start of commercial operation.
3. Pay the application fee based on the OIMB/FO order of payment via bank transfer, postal money order/manager's check or actual
DOE treasury counter payment payable to the Department of Energy;
4. Issuance of License to operate shall not be later than twenty (20) working days from receipt of application;
5. OIMB/FO may further require a presentation on the details of application in a pre-application conference; and
6. Refer to Section 31 of this Department Circular for the DOE handling office of this application

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES )


CITY/MUNICIPALITY OF _____________ ) S.S

BEFORE ME, a Notary Public for and in the City/Municipality of ____________________, this ___
day of __________ 20__, personally appeared presenting his/her identification, to wit:

Competent Evidence of
Name Date & Place of Issue
Identity

known to me and to me known to be the same person who executed and voluntarily signed the foregoing
application, which he/she acknowledged before me as his/her own free and voluntary act and deed, and
with full authority to sign in that capacity.

This application consisting of _______ (__) original copy/ies submitted to OIMB with complete
attachment, duly signed by the applicant.

IN WITNESS WHEREOF, I have hereto set my hand on the day, year and place above the written.

NOTARY PUBLIC

Doc No. ______


Page No. ______
Book No. ______
Series of 20______

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