3526 THE GAZETTE OF PAKISTAN, EXTRA., DECEMBER 20, 2010 [PARTI FORM PvV-1 [see rules 160(2), and 168(3)] Application for grant, amendment or renewal of a license to store or store and dispense liquefied petroleum gas in liquefied petroleum gas dispensing station as automotive fuel to motor vehicles. {RELEVANT DOCUMENTS LISTED OVERLEAF MUST BE ENCLOSED WITH THIS APPLICATION IE IT IS FOR THE GRANT OF A LICENCE IN FORM PY -V or PV-II) (Replies to be written in the relevant box) 1. Name in which license is required to be granted. (See notes below) Name, National Identity Card No. 2. Status (Tick the relevant box) Individual Company _ Society 3. Applicant's address Postal address Permanent Address Telephones Nos Telex / E. Mail 4, Qualification and experience of applicant and technical personnel employed by him. (Attach separate sheet if required) Name. | Designation. | Qualifications. Experience.Part U]_ THE GAZETTE OF PAKISTAN, EXTRA., DECEMBER 20, 2010 3527 5. Situation of premises— Province. | District. | Town or | Survey | Police Railway village. | No.. | Station. | Station. 6, Liquefied Petroleum Gas proposed to be stored: Chemical ame Daas of LPO Vesscis to be ted Toa quan and composition of of the Liquefied Liquefied Pewoleum Gas Petroleum Gas. ‘Nature. ‘Nos. 7 Capacity Manufacturer’ efeach | name and origin. vessel Above gad ‘Under-ground Mounded 7. Have the premises already been licensed? If yes, please give details: Sr] Formor ] License No | licence, No. 8. Additional information, if any Quantity of HP/DP/CNG/LPG already stored No of tanisleyiinders7 vessels3528 __ THE GAZETTE OF PAKISTAN, EXTRA., DECEMBER 20, 2010_ [Part II [hereby declare that the statements made above have been checked up by me and are true and I undertake to abide by the terms and conditions of the license which will be granted to me. Date ve o Signature of applicant Place (Authorized person in case of Company) Full Name . Address Su ASaecesnesasSaiAssASSnSananOOnsaisOOn ag Notes:— (1) In case where application in made in the name of a Company, the names and addresses of Directors and Partners and the name, address and specimen signatures of person ot persons authorized to sign correspondence in respect of license applied for should be given on a separate sheet and enclosed with this application form. Any change in the above information should be immediately communicated to the licensing authority and authority renewing the license. (2) Age to be given in case the applicant is an individual. (3) DOCUMENTS REQUIRED TO BE SUBMITTED WITH APPLICATION FOR A LICENSE () Four copies of specification and plans approved under rule 155 (not required for renewal a license without amendment), (ii) Specification with certificates of dispenser, piping, hoses and other fittings (required for grant or amendment of license). (iii) License together with approved plans and specifications attached thereto. (Not required for first grant of license). (iv) Fee for the grant, amendment or renewal of a license specified under the scheduled, sub-rule (2) of rule 169 and sub-rule (7) of rule 169, as the case may be, to be paid in the manner specified in rule 11. (v) A certificate of safety under rule 102 (not required for renewal of iicense). (4) Delete whichever is not applicable.