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.