Republic of the Philippines

Department of the Interior and Local Government

Bureau of Fire Protection
Region 7
Bohol Provincial Office
SAN MIGUEL FIRE STATION
Poblacion, San Miguel, Bohol
Telephone Number/Email Address: 0965-162-7038/ sanmiguelfire2022@gmail.com

____________________
(Name of Owner) DATE

(Name of Establishment)

(Address)

FOR : CITY/MUNICIPAL FIRE MARSHAL

ATTN : CHIEF, FIRE SAFETY ENFORCEMENT SECTION

REFERENCE: INSPECTION ORDER NO.______________________ DATE ISSUED ______________________

DATE OF INSPECTION:

NATURE OF INSPECT ION CONDUCTED: [ ] Check Appropriate Box

[ ] Building Under Construction [ ] Periodic Inspection of Occupancy
[ ] Application for 0ccupancy Permit [ ] Verification Inspection of Compliance to NTCV
[ ] Application for Business Permit [ ] Verification Inspection of Complaint Received
[ ] Others (Specify) _________________________________________________________________________________

GASOLINE SERVICE STATION CHECKLIST

I. GENERAL INFORMATION
Name of Building __________________________________________________________________________________
Business Name ___________________________________________________________________________________
Address__________________________________________________________________________________________
Nature of Business _________________________________________________________________________________
Name of Owner/Occupant ___________________________________ Contact No. _______________________
Name of Representative_______________________________________ Contact No. _______________________
No. of Storey__________ Height of B1dg. __________ (m) Portion Occupied ______________________________
Area per flr __________________________sqm Total Flr. Area ______________________________sqm
Building Permit No ___________ Date Issue_______ Occupancy Permit No.______ Date Issued _____________
Latest FSIC Issued Control No. _______________ Date Issued _______________ FC Fee ______________________
Certificate of Fire Drill __________________Date Issued_________________ FC Fee ______________________
Latest Notice to Correct Violations Control No. ____________________________ Date Issued __________________
Name of Fire Insurance Co/Co-Insurer________________ Policy No.__________ Date Issued __________________
Latest Mayor's/Bus. Permit _________ Date Issued______ Municipal License No._____ Date Issued __________
Latest Certificate of Electrical Inspection No. __________________ Date Issued _____________________________
Other Information__________________________________________________________________________________

II. UNDERGROUND TANKS

Name of Contractor /Installer _____________________________________ Date Installed______________________

No. Kind of Flammable Capacity Depth of Land Fill Distance Between Tanks

III. VENT PIPES

No. Size Height Flame Arrester Weather hood

IV. PUMPS (Dispensing Unit)

Properly Distance from Distance Adjacent
No. Make Guard Pipe
Supported Street Curb Building

BFP-QSF-FSED-026 Rev. 01 (07.05.19) Page 1 of 3

 Republic of the Philippines
Department of the Interior and Local Government
Bureau of Fire Protection

A. EMERGENCY LIGHTS
Automatic Emergency Lights Provided? [ ] Yes [ ] No Source of Power [ ] AC/DC [ ] Others ___________________
No. of Units per Floor___________ Located at: Hallways _____________ Stairway Landings ___________________
Operational: [ ] Yes [ ] No Exit path properly illuminated? [ ] Yes [ ] No
Tested monthly: [ ] yes [ ] No Minimum AEL Power Duration: at least one (1) hour

B. WARNING/SAFETY SIGNS
[ ]”No Smoking” [ ] “Dead End” [ ] Elevator Sign [ ] Keep Door Closed
Other, specify _____________________________________________________________________________________

V. FIRST AID FIRE PROTECTION EQUIPMENT (PORTABLE FIRE EXTINGUISHERS)

Type__________________ Capacity ____________________________ No. of Units____________________________
With PS Mark? [ ] Yes [ ] No With ISO Mark? [ ] Yes [ ] No
Properly Maintained?[ ] Yes [ ] No Conspicuously Located? [ ] Yes [ ] No Accessible? [ ] Yes [ ] No
Other Types Provided, if any _________________________________________________________________________

VI. OTHER FIRE SAFETY FEATURES:

Number of Lubricating Bays __________________________________________________________________________
Number of wash racks_______________________ Crank case drainage provided? [ ] Yes [ ] No
Oil/Water separator provided? [ ] Yes [ ] No
Perimeter/fire wall provided? [ ] Yes [ ] No Height ____________________________________
Any opening? [ ] Yes [ ] No
Dispensing platform provided? [ ] Yes [ ] No Height within limit? [ ] Yes [ ] No
Manhole tank cover made of____________ Thickness __________ Gasketed? [ ] Yes [ ] No
Housekeeping: [ ] Poor [ ] Good
Any refreshment stand being operated inside premises? [ ] Yes [ ] No

VII. DEFECTS / DEFICIENCIES NOTED DURING INSPECTION (Attached pictures, sketch and others)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________.

VIII. RECOMMENDATIONS
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

ACKNOWLEDGED BY:

________________________________________ _____________________________________________
Signature Over Printed Name of Owner/ Fire Safety Inspector/s
Representative

Date & Time ____________________________ ______________________________________________

Team Leader

RECOMMEND ISSUANCE OF FSIC/NTC/NTCV:

______________________________________________
CHIEF, FIRE SAFETY ENFORCEMENT SECTION

APPROVED / DISAPPROVED:

_____________________________________________
CITY / MUNICIPAL FIRE MARSHAL

PAALALA: “MAHIGPIT NA IPINAGBABAWAL NG PAMUNUAN NG BUREAU OF FIRE PROTECTION SA MGA KAWANI NITO ANG
MAGBENTA O MAGREKOMENDA NG ANUMANG BRAND NG FIRE EXTINGUISHER”

“FIRE SAFETY IS OUR MAIN CONCERN”

DISTRIBUTION:
Original (Applicant/Owner’s Copy)
Duplicate (BO or BPLO, as the case may be)
Triplicate (BFP Copy)

BFP-QSF-FSED-026 Rev. 01 (07.05.19) Page 2 of 3

 Republic of the Philippines
Department of the Interior and Local Government
Bureau of Fire Protection

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