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Republic of the Philippines

Department of Environmental and Natural Resources
ENVIRONMENTAL MANAGEMENT BUREAU
Region III
Masinop cor. Matalino St., Diosdado Macapagal Government Center, Brgy. Maimpis, City of San
Fernando, Pampanga
Tel No: (045) 963-3623

APPLICATION FOR REGISTRATION

OF DEALERS AND RETAILER/RE-SELLERS OF ODS

A. GENERAL INFORMATION

1. Company/Business Name
AC LIQUID NITRO REF AND CAR AIRCON PARTS
2. Name of Business Owner
AUGUST CUNANAN
3. Type of Ownership Sole
4. SEC / DTI Registration Number / Business Permit No
1103550
5. Business Address
207 STALL 1 MAC ARTHUR HI-WAY Dau MABALACAT CITY PAMPANGA
6. Contact Person Information
Name AUGUST B. CUNANAN
Telephone No 09173683649
Fax No 045-3080385
Mobile No 0917-368-3649
Email acliquidnitro@gmail.com
7. Business Category
✔ With Refilling Activity
Without Refilling Activity
Other Activities
8. Storage Facility PUROK 1 Bical MABALACAT CITY PAMPANGA
Zip Code 2010
Area (m2) 28
Capacity kg / 28 MT

B. SALES HISTORY (FOR THE PAST TWO YEARS) (IN KILOGRAM/S) OF ODS

Name of ODS Source(s) Type Quantity Purchased

None

C. PROJECTED CHEMICALS TO BE SOLD/DISCOVERED BY THE REGISTRATION FOR THE YEAR (IN

KILOGRAM/S)
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Name of ODS Source(s) Type Quantity Purchased

None

D. ANNUAL REPORT (SUMMARY OF TRANSACTIONS)

(See attached Summary of Transactions in the Requirements)

E. NOTARIZED CERTIFICATION

THE UNDERSIGNED CERTIFY THAT THE INFORMATION PROVIDED IN THIS FORM IS TRUE AND
ACCURATE.

NAME
DESIGNATION / POSITION

SIGNATURE DATE

I acknowledge that this application form is a legally binding document, and I declare, under the penalties of
perjury, that the same has been accomplished in good faith, verified by me, and, to the best of my knowledge
and belief, is true and correct pursuant to the regulations issued under authority thereof.

(Notary Public)