Department of Energy Annex G-1
Oil Industry Management Bureau (OIMB) September 2022
CHECKLIST OF REQUIREMENTS
LPG RETAILER
APPLICATION FOR ISSUANCE OF LICENSE TO OPERATE (LPG)
Company Name: PERAN LPG SUPPLY Contact Details (email and tel #):
[email protected] +639267460501
Prepared By: Approved By:
Florie May P. Gaborni/Owner
(Position and Signature over Printed Name) (Position and Signature over Printed Name)
REQUIREMENTS SUBMITTED (Y/N) / REMARKS
1. Notarized application form – Annex G;
2. Checklist of requirements - Annex G-1;
3. Company profile form – Annex G-2;
4. Outlet profile form - Annex G-3;
5. List of transport motor vehicle on per total company basis with supporting documents - Annex G-4; and
6. Attached Supporting Documents:
6.1. Executive briefer of operation;
6.2. Scaled layout plan of the establishment;
6.3. Business registration for the applied business activity from the Securities and Exchange Commission or Department of Trade and Industry or Cooperative
Development Authority (whichever is applicable);
6.4. Articles of Incorporation if SEC registered or its equivalent if DTI registered;
6.5. Latest GIS if SEC registered or its equivalent if DTI registered;
6.6. Business permit for the applied business activity from the Local Government Unit or PEZA Certificate of Registration;
6.7. Bureau of Internal Revenue registration for the applied business activity;
6.8. Certificate of registration and official receipt per motor vehicle from LTO with corresponding picture of the front of vehicle with plate number;
6.9. Conveyance Permit per motor vehicle from the Bureau of Fire Protection.
6.10. Fire safety inspection certificate per establishment from the Bureau of Fire Protection;
6.11. Occupancy permit per establishment from the Local Government Unit;
6.12. Notarized certification on the supplier's contract/agreement with the LPG Dealer
6.13. List of qualified service personnel with attached certificate of training conducted by DOE recognized training organization;
6.14. Latest digital photographs (5R Size with date/time stamp) showing the following:
6.14.1. Full and front and back views of the establishment;
6.14.2. Price display board;
6.14.3. Measuring device/s;
6.14.4. LPG cylinders; and
6.14.5. Safety and informational signs; and
6.14.6. Display board showing the Facility registered business name and address.
6.15. Fire prevention and response manual;
6.16. Clearance certificate from the Legal Services - No pending penalty or prohibition to engage in the LPG Activity;
6.17. Notarized company secretary's certificate for authorized representative and signatory; and
6.18. Proof of payment of application fee.
Reminder/ Instruction:
1. Submit one (1) Certified True Copy of all the required supporting documents.
Page 1 of
Department of Energy Annex G-2
Oil Industry Management Bureau (OIMB) September 2022
COMPANY PROFILE
LPG RETAILER
APPLICATION FOR ISSUANCE OF LICENSE TO OPERATE (LPG)
Company Name: PERAN LPG SUPPLY Contact Details (email and tel #): [email protected] As of (mm/dd/yyyy):
Prepared By: Approved By:
Florie May P. Gaborni/Owner
(Designation and Signature over Printed Name) (Designation and Signature over Printed Name)
I. COMPANY BACKGROUND
Business Address (Number, Street, Brgy., Mun/City, Province and Region): #26 Brgy. Jibong Barcelona Sorsogon city GPS Coordinates: Longitude: Latitude:
Telephone (landline) No.: +639267460501 E-mail Address:
President/CEO/Owner: Florie May P. Gaborni
Authorized Representative/s to transact business with DOE:
Type of Ownership: ( / ) Single Proprietorship ( ) Partnership ( ) Corporation ( ) Cooperative
Registered Owner / Partners / Incorporator / Board of Directors:
Name Nationality
Florie May P. Gaborni FILIPINO
*add row/s as necessary
Executive Management Organizational Structure:
Name Designation/Position
*add row/s as necessary
Number of employee/s: (attach Organizational Structure and indicate number of staff/employees per position per facility, including outsourced employee/s):
II. DESCRIPTION OF BUSINESS PORTFOLIO
Background
History of operations and investments in the Philippines
Expansion Program/s
LPG Brand/s and Size/s:
LPG Source:
Name of supplier Address of Supplier
*add row/s as necessary
III. FACILITIES - Outlet and Warehouse
Location or Address Valid Until
License to Operate No.
Type of Facility Name
Region Province Municipality/City Barangay Street (For LPG)
(dd/mm/yyyy)
A. Company Owned and Operated
Eco Savers Business Hub
Region V Sorsogon Barcelona
Inc.
*add row/s as necessary
B. Company Owned but Privately Operated
*add row/s as necessary
C. Privately Owned and Operated
*add row/s as necessary
IV. COST OF INVESTMENT (Company Owned)
Details Cost in Philippine Peso Number of Manpower Requirement per facility
A. Outlet
B. Warehouse
C. Total Operational Cost
TOTAL
Department of Energy Annex G-3
Oil Industry Management Bureau (OIMB) September 2022
OUTLET PROFILE
LPG RETAILER
APPLICATION FOR ISSUANCE OF LICENSE TO OPERATE (LPG)
Company Name: Contact Details (email and tel #): [email protected] As of (mm/dd/yyyy):
PERAN LPG SUPPLY
Prepared By: Approved By:
Owner/Florie May P. Gaborni
(Designation and Signature over Printed Name) (Designation and Signature over Printed Name)
Retail Outlet Classification: Pure LPG Retailer With other merchandise
I. ESTABLISHMENT PROFILE:
Establishment Business Name: ECO SAVERS BUSINESS HUB INC. GPS Coordinates:
Business Address (Number, Street, Brgy., Mun/City,
ZONE 8, BULAN SORSOGON Longitude:
Province and Region):
Telephone (landline) No.: Latitude:
Date of Start of Operation: Email Address:
Cost of Investment (PhP):
Type of Ownership: ( / ) Single Proprietorship ( ) Partnership ( ) Corporation ( ) Cooperative
Total Number of Personnel in the Facility: 3
II. EXECUTIVE MANAGEMENT ORGANIZATIONAL STRUCTURE
Name Designation
*add row/s as necessary
III. RETAIL OUTLET FACILITIES
Storage Area/ Showroom
Floor area (sq.m) for filled and empty LPG cylinders Size/s Quantity LPG Brand/s
Less than 1kg
2.7kg
5kg
7kg
11kg 10 Eco Savers Gas
22kg
50kg
*Refer to Annex F-4 on Retail Outlet Classification and Annex __ for Facility Standard Requirements
IV. FIRE FIGHTING SYSTEM
No. of Units Type / Class Location
A. No. Fire Extinguisher 3 ABC
B. Water Sprinkler
C. Gas Detector
D. Water Supply Source
E. Safety and Informational Signs
Other Observations/Information:
Reminder/ Instruction:
1. Submission of this report shall be on a per establishment basis.
Department of Energy Annex G-4
Oil Industry Management Bureau (OIMB) September 2022
LIST OF TRANSPORT MOTOR VEHICLE
LPG RETAILER
APPLICATION FOR ISSUANCE OF LICENSE TO OPERATER (LPG)
Company Name: PERAN LPG SUPPLY Contact Details (email and tel #): 09267460501 As of (mm/dd/yyyy):
[email protected]
Prepared By Approved By:
(Position and Signature over Printed Name) (Position and Signature over Printed Name)
Land Transportation Office (LTO) Land Transportation Office (LTO)
Bureau of Fire Protection Conveyance Permit Particulars
Certificate of Registration Official Receipt
If Contracted, Company
Plate / Motor Vehicle File Bulk Transport or In Company-Owned or If Contracted, Independent
Type of Vehicle Issued Date OR Number Valid Until Issued Date Valid Until Name of the Independent LTO Validity
Number Cylinder or Cartridge Contracted Hauler LTO Number
Hauler
Supporting Documents - Certified true copy of the following:
1. Certificate of registration and official receipt per motor vehicle from LTO with corresponding picture of the front of vehicle with plate number; and
2. Conveyance Permit per motor vehicle from the Bureau of Fire Protection.
Energy Center, Rizal Drive cor. 34th Street, Bonifacio Global City, Taguig City, Philippines 1632 Tel. No. (Trunkline) (632)8479-2900; Website: http://www.doe.gov.ph; E-mail: [email protected]
Department of Energy Annex G-5
Oil Industry Management Bureau (OIMB) September 2022
Typical Retail Outlet Layout Design
Top View Front View
Empty LPG Cylinders Filled LPG Cylinders
Isometric View
ROA
D
Fire Extinguisher
Ventilation Area
Gas Detector
Display Area - Filled LPG Cylinders
Structural Requirements:
4.) Minimum floor area for filled and empty LPG cylinders is two (2) square meters. (excluding area for
1.) Building shall be made up of predominantly non-combustible material (Concrete/Steel); cashier's booth and display area);
2.) Building should not be part of a Theatre, School, Hotel, Supermarket or a place of worship; 5.) The gas leak detector must be mounted (0.5 to 1.0m - to be verified) from the floor; and
3.) Store should be well ventilated; 6.) No Drains or opening shall be allowed in the floor of the building.
