Form C 38236l

6/19/2014

FORM C FORM C (See Rules 57, 61 and 62) Application for the grant/amendment/renew al of a licence to fill and/or store compressed gas in cylinders:

Documents listed ov erleaf must be enclosed w ith this application, if it is for the grant of a licence in Forms ‘E’ and ‘F’. The replies to be given in this column. 1. Applicant’s name** Applicant's calling Full postal address

_____________ _____________ _____________

2. Situation of the premises where compressed gas is to be stored/filled: State District Town or village Nearest Police Station Nearest Rly. Station

_____________ _____________ _____________ _____________ _____________

3. Nature of each compressed gas proposed to be filled/stored namely:

Quantity

(a) toxic _____________ (b) non-toxic and non-flammable _____________ (c) non-toxic and falmmable _____________ (d) dissolved acetylene gas _____________ (e) non-toxic and flammable liquefiable gas otherthan LPG or _____________ (f) liquefied petroleum gas. _____________ 4. Chemical name of each compressed gas proposed to be filled/stored

_____________

5. Quantity of each compressed gas proposed to be filled/stored in of numbers for gases mentioined under Items 3(a), 3(b), 3(c) or 3(d); and In of Kgs. for gases mentined under _____________ items 3(e) or 3(f) _____________ 6. Nature, chemical name and quantity of each compressed gas alredy filled/stored in the premises.

_____________

7.Number of the licence held for the premises and the full name of the holder of the licence. _________ I hereby declare that the statements made above have been checked up by me and are true and I undertake to abide by the norms and conditions of the licence which will be granted to me. Date of application

Signature and designation of the applicant

** Where the application is made on behalf of a Company, the name and address of the Company and the name of the Manager or Agent should be given and the application should be sigend by him. Every change in the name of the Manager or Agent shall be forthwith intimated to and his specimen signaturefilled with licensing authorrity. DOCUMENTS REQUIRED TO BE SUBMITTED WITH THIS APPLICATIN FOR A LICENCE IN FORM ‘E’ AND ‘F’ 1. Four copies of specificatiions and plans approved under Rule 55. (NOT REQUIRED FOR RENEWAL OF A LICENCE WITHOUT AMENDEMNTS). 2. Licence together with approved plans and specifications attached thereto. (NOT REQUIRED FOR THE FIRST GRANT OR A LICENCE) 3. Requisite amount of fee for the grant, amendment or renewal of a licence paid in the manner specified in Rule

http://peso.gov.in/shirish/af-gas-C.htm

72.

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