DMRE 40

APPLICATION FORM FOR A MANUFACTURING LICENCE

PETROLEUM PRODUCTS ACT 120 OF 1977 AS AMENDED - PETROLEUM PRODUCTS MANUFACTURING LICENCE
REGULATIONS 2006

INSTRUCTIONS OFFICIAL USE ONLY

1. READ REGULATIONS BEFORE COMPLETING THIS APPLICATION FORM.

2. USE CAPITAL LETTERS AND WHERE APPLICABLE MARK WITH A . MANUFACTURING LICENCE NUMBER

/ /

SECTION 1: APPLICANT’S DETAILS

REGISTERED
NAME
IN FULL

TRADE
NAME
IN FULL

POSTAL
ADDRESS OF
REGISTERED
OFFICE

POSTAL CODE

PHYSICAL
ADDRESS OF
REGISTERED
OFFICE

POSTAL CODE

BUSINESS
TEL NO.
(INCLUDE
CODE)

MOBILE PHONE
NUMBER

FAX NO.
(INCLUDE
CODE)

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E-MAIL
ADDRESS

ENTER DETAILS OF CONTACT PERSON

TITLE

FAMILY NAME

FIRST NAME

IDENTITY NO.

SECTION 2: APPLICANT’S BUSINESS DETAILS

Indicate by cross type of entity or specify in “other”

LIMITED LIABILITY COMPANY CLOSE CORPORATION SOLE TRADER

INDIVIDUAL PARTNERSHIP BODY CORPORATE

TRUST OTHER

IF OTHER
(SPECIFY)

REGISTRATION
NUMBER

TAX NUMBER

PLEASE INDICATE OWNERSHIP BY HISTORICALLY DISADVANTAGED SOUTH AFRICANS (HDSA’s) IN

PERCENTAGE


ERF OR STAND OR LOT NUMBER AND TITLE OF PROPERTY AS IT APPEARS ON THE TITLE DEED
OF THE PROPERTY.

PHYSICAL ADDRESS (where Manufacturing activities are/will be carried out)

STREET NAME1

STREET NAME2

STREET No.

SUBURB

TOWN/CITY

POSTALCODE

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MUNICIPAL
AREA/
AUTHORITY

INDICATE PROVINCE WHERE THE MANUFACTURING ACTIVITIES ARE/WILL BE CARRIED OUT

EASTERN CAPE FREE STATE GAUTENG KWAZULU-NATAL

LIMPOPO MPUMALANGA NORTHERN CAPE NORTH WEST

WESTERN CAPE

GLOBAL POSITIONING SYSTEM (GPS) COORDINATES OF PROPERTY WHERE MANUFACTURING

ACTIVITY ARE/WILL BE CARRIED OUT

NOTE: Coordinates must be recorded from the centre of the property, or can be obtained from EIA report.

LATITUDE: degrees, minutes, seconds ° ‘ “

LONGITUDE: degrees, minutes, seconds ° ‘ “

INDICATE VOLUMES IN BARRELS OF OILMANUFACTURED PER DAY OR EQUIVANT THEREOF

MAXIMUM MANUFACTURING CAPACITY

CURRENT MANUFACTURING CAPACITY

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 DOCUMENTS TO BE ATTACHED WITH THE APPLICATION FOR A
MANUFACTURING LICENCE

1. In the case of an application made by an applicant who does not qualify in terms of section 2D
of the Act, a motivation for the manufacturing activity.

2. A certified copy of the title deed of the property on which the manufacturing facility is located or
is proposed to be located and where applicable, the written permission of the owner of the
property on which the manufacturing facility is located or is proposed to be located.

3. A certified copy of the applicant’s identity document, if the applicant is a natural person, and in
the case of a non- South African citizen, permanent residence permit or employment permit
and proof of residence in South Africa, or proof of domicile in South Africa, as the case may
be.

OR

a certified copy of the business entity's registration documents, if the applicant is a corporate
entity or a trust.

4. A declaration by the applicant stating that the applicant is in compliance with the Charter or a
statement of its plans to meet the requirements of the Charter.

5. In the case of an application made by an applicant who does not qualify in terms of section 2D
of the Act, certified copies of-

a. the land use zoning certificate issued by a competent authority, authorising the
manufacturing activity on the property.

and

b. the Record of Decision of the environmental authorities in accordance with the

Environmental Conservation Act,1989 (Act No. 73 of 1989), as amended or the
National Environmental Management Act, 1998 (Act No. 107 of 1998), as amended,
permitting manufacturing operations on the property.

6. A declaration by the applicant stating that the applicant is in compliance with the Act, the
referred Regulations and all other national, provincial and local government laws applicable for
the operation of the activity concerned, including but not limited to laws relating to labour,
safety, hazardous substances, security, health and environment.

7. If necessary, the original or certified copy of a declaration by the applicant giving reasons why
any attachment required is not provided.

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DECLARATION

I (full names)………………………………………………………………………..…..hereby declare

that all information provided herein is within my personal knowledge and that-
a) I am duly authorised to make this declaration;
b) I am the designated person responsible for this licence and any
conditions attached thereto;
c) I have read and understood the regulations related hereto, with specific
reference to Regulation 27 regarding any false declaration; and
d) all information provided herein is to the best of my knowledge true and
correct.

Signed at…………………..……(place) on this.……. day of…….………...……(month)

………………. (year)

……………………..………………...
Signature

I certify that the deponent-

(a) has acknowledged that he/she knows and understands the contents
of this application form and its annexures, that he/she has no
objection to taking the prescribed oath and that he/she considers the
oath binding on his/her conscience; and
(b) has in the prescribed manner sworn that the contents of this
application form and its annexures are true and signed same before
me at ……………..…………. (place) on this …………day of
………………………..………(month)……………….….(year).

_________________________________
COMMISSIONER OF OATHS

Name: _____________________________________________________________

Address: ___________________________________________________________

Capacity: ___________________________________________________________

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NOTE: If this application form is completed electronically it must be printed
out, signed before a Commissioner of Oaths and submitted with the
necessary supporting documents and submitted to the appropriate regional
office using the relevant address, mentioned below.

Gauteng Western Cape Kwazulu- Natal

Private Bag X96 Private Bag X9 Private Bag X 54307
Pretoria Roggebaai Durban
0001 8012 4000

Physical Address Physical Address Physical Address

Matimba Building, Constitutional House Durban Bay House
192 Visagie Street, Cnr Paul Kruger Cnr Adderley & Church Street 333 Smith Street
& Visagie Street Cape Town Durban
Pretoria 8001

Tel: 012 406 7788 Tel: 021 446 3301 Tel: 031 334 7703
Eastern Cape Free State Mpumalanga
Private Bag X6076 Private Bag X33 P.O BOX 17851
Port Elizabeth Welkom Witbank
6000 9460 1035

Physical Address Physical Address Physical Address

Waverly Office Park, 3-33 The Strip Building ABSA Building
Phillip Frame Park 314, Cnr Stateway & Bok Cnr Rhodes & High Avenue
Chisselhurst Street Witbank
East London Welkom
9460

Tel: 043 703 6000 Tel: 057 391 1326 / 1375 Tel: 013 658 1402
North West Northern Cape Limpopo
Private Bag XA1 Private Bag X6093 Private Bag X9712
Klerksdorp Kimberley Polokwane
2570 8301 0700
(053) 807 1752
Physical Address Physical Address
Katlego House, 21 Physical Address 18A Landros Mare
Connaught Street 41 Schmidtsdrift Road & 20 Landros Mare Street
Mafikeng Drakenburg Avenue Polokwane
North West Kimberly 0700

Tel: 018 397 8604 Tel: 053 836 4000 Tel: 015 230 3600

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