OIMB/COR#022-COCD

APPLICATION FOR SECURING CERTIFICATE OF COMPLIANCE (COC)

Business Name: _____________________________________________________________________________

(as indicated in DTI/SEC/CDA Registration)

Name of Dealer/Owner: ____________________________________________ Start of Operation: __________

Complete Address of Establishment: _____________________________________________________________

____________________________________________________________________________________________

Telephone No.: _______________________________ Cell Phone No.: ______________________________

Fax No.: _______________________________ E-mail address: ______________________________

Type of Ownership:

Single Proprietorship Partnership Corporation

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

Please write COMPLIED or NOT COMPLIED in the space provided

__________________________ Compliance to environmental laws by DENR-EMB

__________________________
__________________________
__________________________
__________________________
__________________________
Compliance to local Zoning Ordinance
Compliance to Fire Code of the Philippines
No Above-ground tank(s)
Dispensing fuels through the use of prescribed dispenser(s), with no “bote-
bote” or similar containers in use
Compliance to local Building Code

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

Supplier(s): _________________________________________________________________________________

In Case of Corporation, Authorized Representative(s): _______________________________________________

Name of Owner/Partner(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 __________________________________
(Name)
,of ________________________________________, Known to me to be the person whose name is subscribed to the
(Name of Company)
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 ____________________, 201___.

NOTARY PUBLIC

Doc. No.
Page No.
Book No.
Series of ________.
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