OIMB/COR#023-COCDrev1

APPLICATION FOR SECURING CERTIFICATE OF COMPLIANCE (COC)

Type of Ownership:

Single Proprietorship Partnership Corporation

Business Name:
(as indicated in DTI / SEC / CDA Registration)

Name Dealer/Retailer: Start of Operation: _____ _____

(as indicated in DTI / SEC / CDA Registration)

Name of Applicant:
(Partner / Incorporator / Authorized Representative)

Complete Address of Retail Outlet:

Telephone No.: Cell Phone No.:

Fax No.: E-mail Address:

Cost of Investment: (Please attached detail of Project Cost)

Please write COMPLIED or NOT COMPLIED in the space provided

DENR-EMB ECC/CNC
Local Zoning Ordinance
Fire Safety Inspection Certificate
Business Permit
Building Permit

Do you have Tank Truck(s) for Hauling Liquid Fuels (Own-Use)? Yes No
(If YES, please attach additional requirements)

Supplier(s):

Address:

Telephone No.: Cell Phone No.:

Fax No.: E-mail Address:

______________________________________
(Signature over Printed Name of Applicant)

Before me, the undersigned authority, on this day personally appeared _____________________________________,
of ________________________________________, Known to me to be the person whose name is subscribed to the
(Business Name)
foregoing instrument, consisting of ___ attachments including this page on which this acknowledgement is written,
and 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 ____________________, 20___.

NOTARY PUBLIC

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