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APPLICATION FOR SECURING CERTIFICATE OF COMPLIANCE (COC)
business Name: - —————
(GET W DTUSETCDR RegaovOnT
Name of Dealer/Owner: Start of Operation:
Complete Address of Establishment:
“Telephone No. Cell Phone No,
Fax No. emai adress:
“Type af Ownership:
1 sinote Proprietorship 1 Portnership 1 cororation
cost of Investment: (Peace attached detail of Project Cost)
Please write COMPLIED or NOT COMPLIED in the space provided
Compliance to environmental laws by DENR-EMB.
Compliance to local Zoning Ordinance
Compliance ta Fire Cade of the Philippines
No Above-ground tank(s)
a Dispensing fuels through the use of preserbed dispenser(s), with no "bote-
bote” or similor containers in use
Comaliance to local Building Code
2 you have Tak Trck( for Hang guid Fuels (Own-use)? [I] Yes wo
EYES lnc atiach adore equrement) a a
Suppliers):
In Case of Corporation, Authorizes Representative(s)
Name of Owner/Partner(s)
address = ps
“Telephone No, CellPhone No
Fax No. Email adress:
‘ignature aver Printed Name of Applicant) —
Before me, the undersigned authority, on this day personally appeared
of Known to me to be the person whose names subscribed to the
foregoing instrument, consisting of ___ attachments including this page on which this acknowledgement is written,
Sna'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
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