FORM PV- I

[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 IF IT IS FOR THE GRANT OF A LICENCE IN FORM PV –V or PV-III)

(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.

5. Situation of premises –

Province. / District. / Town or village. / Survey No. / Police Station. / Railway Station.

6. Liquefied Petroleum Gas proposed to be stored:

Chemical name and composition of Liquefied Petroleum Gas. / Details of LPG Vessels to be installed / Total quantity of the Liquefied Petroleum Gas.
Nature. / Nos. / Capacity of each vessel. / Manufacturer name and origin.
Above-ground
Under-ground
Mounded

7. Have the premises already been licensed? If yes, please give details:

Sr.No. / Form of licence. / License No. / Quantity of HP/DP/CNG/LPG already stored.
HP / DP / CNG / LPG / No of tanks/cylinders/ vessels
1
2

8. Additional information, if any

I 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 …………………………… Signature of applicant

Place ………………………….. (Authorized person in case of Company)

Full Name ……………………………….

Address ………………………………….

………………………………….

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 or 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

(i) 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 license).

(4) Delete whichever is not applicable.