AFFIDAVIT OF DESIGNATED REPRESENTATIVE OF

THE PROPONENT

I, ____JERRYSON C. ARCALES hereby designate __DANILO M. CABILAN JR.____, as my

official representative on ___J.C.A. POWER FUEL STATION____ with respect to the filing of Compliance
Monitoring Report (CMR) in accordance with Section 19 (a) of the Revised Procedural Manual for DENR
Administrative Order No. 30, Series of 2003 and to confirm THAT:

1. All the information and commitments in this Compliance Monitoring Report (CMR) dated
JANUARY 5 2023 for the ____J.C.A. POWER FUEL STAION_____ with ECC Ref. No. __ECC-
OL-R08-2019-0105____ are accurate and complete to the best of our knowledge and
documents available on file;

2. No DENR-EMB personnel was directly involved in the preparation of this Compliance

Monitoring Report (CMR); and

3. I hereby bind myself to answer any penalty that may be imposed arising from any
misrepresentation or failure to state material information in this CMR REPORT;

This designation will remain in effect until revoked by written notice.

IN WITNESS WHEREOF, I hereby set my hand this _____ day of ________________ at

_____________________________________.

_____JERRYSON C. ARCALE_______
NAME OF PROPONENT HEAD
MANAGING HEAD__________________
J.C.A. POWER FUEL STATION___________
294-977-266-0000_______________

CONFORME:

___DANILO M. CABILAN JR_______________

Name of Representative
H04-20-000562______________

SUBSCRIBED AND SWORN to before me this _____ day of _____________________, Affiant

exhibited to me his/her respective official identifying documents as stated above which are competent
evidence of identity.

Doc. No._______
Page No._______
Book No._______
Series of _______