CHECKLIST OF REQUIREMENTS: FOR SECURING CERTIFICATE OF COMPLIANCE (COC) ‘As provided for in DOE Department Circular DC2017-11-0011 ‘imeyconeor7-coco [ TOBE FILLED-OUT BY BOE-OIMG LIQUID FUELS OFFICERS ONLY ‘Type of Application: [“]New [~]Renewat [—] Reportorial []Change dealer/name Tera ‘Business Name: Name of RO: Dealer/Retaller: ‘Start of Operation: ‘Complete Address of the Establishment: 1D ot company: [Lr independent: name of Supplier: Remarks REQUIREMENTS (ates Submisscr . PRIOR NOTICE 1, Filled-out and notarized application form complete with the following information: 1. Business name, address, telephone, fax number and e-mail address of the business office: b. Location and complete address of the Retail Outlet; and ©. Name of dealer in case of ‘single proprietorship, or partners in case of partnership, or authorized representative in case of Corporation. Oo 2. A Notice of Undertaking on liability in case of violations committed by dealer, ‘operator, owner or proprietor. If. SUPPORTING DOCUMENTS FOR 1" ISSUANCE, 4. Certification from distributor/supplier/dealer’s agreement 2. Notarized Statement that the facility design and operation of the Retail Outlet is PNS-compliant signed by the Engineering Procurement Construction Contractor land desler/aviner of the Retail Outlet. 3. List of dispensing pumps/noses end underground storage tank/s with ‘corresponding capacity/ies 4, Scaled lay-out plan showing the island/dispensing pumps, underground storage tanks, cashier's booth and other facilities, oWo;oO}; oo jo ‘Accomplished DOE Form on Undertaking 6. Latest photographs (in SR size) showing! Cruntront, ight, and left side views Price display boara } Cihteaured stickers/iabels for RON, €20 []Safety and informational sians [and Bi, among others OE SCC/COC Clearance of No Pending Case, as applicable 8._Payment of fee TIE. SUPPORTING DOCUMENTS FOR RENEWAL “Application MUST be filed a month ‘Accomplished DOE Form on Undertaking Certification from distributor/supplier/dealer’s agreement DOE SCC/COC Clearance of No Pending Case, as applicable Photocopy of previous COC 5._Payment of fee. IV, REPORTORIAL REQUIREMENTS (Under oath; submitted every 30" day of Januat 1, Data on Purchase and Sales Volume. 2. Certification from distributor/supplier/dealer’s agreement oO g jore COC expiration oosxoooo00) - an Toes CORRESPONDING FEES 1. Acknowledgement of Note/Engegerenton the boIF —S00.00 Dy J orearRecen Seer rer cerca Sees Thaw hpplcaten):'® 300000 | no. 5 Sie emis aati 2 Year anooen 200.00 Ee sioner bate eran ih ier Fanos Sg poi ide Sietinien Aout Energy center, for, PNOC Bla. §, 8GC, Teguia Cy Recommendation: [-] Forwarded to 08D Assessed by: et Co Returned to applicant rete Vas and Sanat) Energy Centr, Rizal Dv, Boniacio Gcba City, Tagua Gry. Prtppres Tel No #752000 oe 376040-2404 Webste yn.don aoegh, E-maefeBdoe 906