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Form C

This document is an application form for obtaining or renewing a license to fill and store compressed gases in cylinders. It requests information such as the applicant's name and address, location of the premises, types and quantities of gases to be filled/stored, existing license details if any. The applicant needs to declare that they will abide by licensing norms and conditions. Certain documents like approved specifications, plans and existing license details need to be submitted along with the application depending on whether it is for new license, renewal or amendment.

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2K views1 page

Form C

This document is an application form for obtaining or renewing a license to fill and store compressed gases in cylinders. It requests information such as the applicant's name and address, location of the premises, types and quantities of gases to be filled/stored, existing license details if any. The applicant needs to declare that they will abide by licensing norms and conditions. Certain documents like approved specifications, plans and existing license details need to be submitted along with the application depending on whether it is for new license, renewal or amendment.

Uploaded by

jacobpm2010
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
Download as pdf or txt
Download as pdf or txt
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6/19/2014 FORM C

http://peso.gov.in/shirish/af-gas-C.htm 1/1
FORM C
(See Rules 57, 61 and 62)
Application for the grant/amendment/renewal of a licence to fill and/or store compressed gas in cylinders:
Documents listed overleaf must be enclosed with this application, if it is for the grant of a licence in Forms E and F.
The repl i es to be gi ven i n thi s col umn.
1. Appl i cants name** _____________
Appl i cant's cal l i ng _____________
Ful l postal address _____________
2. Si tuati on of the premi ses where compressed gas i s to be stored/fi l l ed:
State _____________
Di stri ct _____________
Town or vi l l age _____________
Nearest Pol i ce Stati on _____________
Nearest Rl y. Stati on _____________
3. Nature of each compressed gas proposed to be fi l l ed/stored namel y: Quanti ty
(a) toxi c _____________
(b) non-toxi c and non-fl ammabl e _____________
(c) non-toxi c and fal mmabl e _____________
(d) di ssol ved acetyl ene gas _____________
(e) non-toxi c and fl ammabl e l i quefi abl e gas otherthan LPG or _____________
(f) l i quefi ed petrol eum gas. _____________
4. Chemi cal name of each compressed _____________
gas proposed to be fi l l ed/stored
5. Quanti ty of each compressed gas proposed to be fi l l ed/stored i n terms of numbers for gases menti oi ned under
Items 3(a), 3(b), 3(c) or 3(d); and In terms of Kgs. for gases menti ned under _____________
i tems 3(e) or 3(f) _____________
6. Nature, chemi cal name and quanti ty of each compressed gas al redy _____________
fi l l ed/stored i n the premi ses.
7.Number of the l i cence hel d for the premi ses and the ful l name of the hol der of the l i cence. _________
I hereby decl are that the statements made above have been checked up by me and are true and I undertake to abi de by the norms and condi ti ons
of the l i cence whi ch wi l l be granted to me.
Date of appl i cati on Si gnature and desi gnati on of the appl i cant
** Where the appl i cati on i s made on behal f of a Company, the name and address of the Company and the name of the Manager or Agent shoul d be
gi ven and the appl i cati on shoul d be si gend by hi m. Every change i n the name of the Manager or Agent shal l be forthwi th i nti mated to and hi s
speci men si gnaturefi l l ed wi th l i censi ng authorri ty.
DOCUMENTS REQUIRED TO BE SUBMITTED WITH THIS APPLICATIN FOR A LICENCE IN FORM E AND F
1. Four copi es of speci fi cati i ons and pl ans approved under Rul e 55.
(NOT REQUIRED FOR RENEWAL OF A LICENCE WITHOUT AMENDEMNTS).
2. Li cence together wi th approved pl ans and speci fi cati ons attached thereto.
(NOT REQUIRED FOR THE FIRST GRANT OR A LICENCE)
3. Requi si te amount of fee for the grant, amendment or renewal of a l i cence pai d i n the manner speci fi ed i n Rul e 72.

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