GASOLINE SERVICE STATION CHECKLIST
REFERENCE:
lnspection Order No. (lO)
*
Business Identification Number (BIN) / Business Account Number (BAN)
*
Kindly encode the exact BIN/BAN
IO Date lssued
*
-
Month
-
Day
Year
Date lnspected
*
-
Month
-
Day
Year
NATURE OF INSPECTION CONDUCTED (Check appropriate box)
NATURE OF INSPECTION CONDUCTED (Check appropriate box)
*
Building Under Construction
Application for Occupancy Permit
FSIC for Business Permit (New)
FSIC for Business Permit (Renewal)
Periodic Inspection of Occupancy
Verification Inspection of Compliance to NTCV
Verification Inspection of Complaint Received
Notice of Disapproval, if Certificate of Occupancy
Other
FSI Name
*
All Capital Letters
FSI Email Address
*
***REMARKS ON ESTABLISHMENT***
*
Please Select
OPEN
PERMANENTLY CLOSED/RETIRED ESTABLISHMENT
CLOSED DUE TO COMMUNITY QUARANTINE GUIDELINES
CANNOT BE LOCATED
BUSINESS TRANSFERRED
NOT OPERATIONAL
NOT EXISTING
CHANGE OF BUSINESS NAME
DOUBLE IO/ALREADY INSPECTED
RESCHEDULED
REFUSED ENTRY
Submit
I. GENERAL INFORMATION
Business Identification Number (BIN) / Business Account Number (BAN)
Name of Building
All Capital Letters (Ex: JUAN DELA CRUZ BUILDING)
Address
Business Name
All Capital Letters (Ex: JUAN DELA CRUZ STORE)
Nature of Business
EX: SARI-SARI STORE, RETAILER, CLINIC, GEN. MDSE, SPA
Name of Owner/Occupant
All Capital Letters
Phone Number
Ex: 09191234567
Name of Representative
Email Address of Owner/Representative
No. of Storey
Height of Building (m)
Portion Occupied
Area per floor (sqm)
Total Floor Area (sqm)
Building Permit No.
Date issued
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Month
-
Day
Year
Date
Occupancy Permit No:
Date issued
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Month
-
Day
Year
Date
Latest FSIC Control No.
Date lssued
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Month
-
Day
Year
Date
FC Fee
Certificate of Drill
Date lssued
-
Month
-
Day
Year
FC Fee
Latest Notice to Correct Violations Control No.
Date lssued
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Month
-
Day
Year
Date
Name of Fire lnsurance Co/Co-Insurer
Policy Number
Date lssued
-
Month
-
Day
Year
Latest Mayor's/Bus. Permit
Date
-
Month
-
Day
Year
Date
Municipal License No.
Date
-
Month
-
Day
Year
Date
Latest Certificate of Electrical Inspection No.
Date
-
Month
-
Day
Year
Date
Other Information
II. UNDERGROUND TANKS
Name of Contractor /Installer
Date Installed
-
Month
-
Day
Year
Date
Underground Tanks
No.
Kind of Flammable
Capacity
Depth of Land Fill
Distance Between Tanks
*
*
*
III. VENT PIPES
No.
Size
Height
Flame Arrester
Weather hood
*
*
*
IV. PUMPS (Dispensing Unit)
No.
Make
Properly Supported
Guard Pipe
Distance from Street Curb
Distance Adjacent Building
*
*
*
*
A. EMERGENCY LIGHTS
Automatic Emergency Lights Provided?
Yes
No
Source of Power
AC
DC
Other
No. of Units per Floor
units per flr
Located at Hallways
Stairways Landings
Operational?
Yes
No
Exit path properly illuminated?
Yes
No
Tested Monthly?
Yes
No
Minimum AEL Power Duration: at least one (1) hour
B. WARNING/SAFETY SIGNS
Warning/Safety Signs
"No Smoking"
"Dead End"
"Elevator Sign"
"Keep Door Closed"
Other
V. FIRST AID FIRE PROTECTION EQUIPMENT (PORTABLE FIRE EXTINGUISHER)
Type
Capacity
Number of units
With PS Mark?
Yes
No
With ISO Mark?
Yes
No
Properly Maintained?
Yes
No
Conspicuously Located?
Yes
No
Accessible?
Yes
No
Other Types Provided if any
VI. OTHER FIRE SAFETY FEATURES:
Number of Lubricating Bays
Number of wash racks
Crank case drainage provided?
Yes
No
Oil/Water separator provided?
Yes
No
Perimeter/fire wall provided?
Yes
No
Height
Any Opening?
Yes
No
Dispensing platform provided?
Yes
No
Height within limit?
Yes
No
Manhole tank cover made of
Thickness
Gasketed?
Yes
No
Housekeeping
Poor
Good
Any refreshment stand being operated inside premises?
Yes
No
VII. DEFECTS / DEFICIENCIES NOTED DURING INSPECTION
DEFECTS / DEFICIENCIES
VIII. RECOMMENDATIONS
FSI Recommendation
Please Select
For Issuance of FSIC
For Issuance of NTC
Recommendation
Comply the following DEFFECTS/DEFICIENCIES stated above and pay the corresponding Fire Code Fees including the Storage Clearance Fee , Conveyance Clearance Fee before the issuance of Fire Safety lnspection Certificate (FSIC).
Fire Code Fees to pay:
Please Select
Fire Code Fee
Storage Clearance Fee
Conveyance Clearance Fee
For Issuance of:
Notice to Comply
Notice to Correct Violation
Closure Order
Abatement Order with Administrative Fine
Closure Order for the non-Payment of Administrative Fine
Notice of Disapproval, if Certificate of occupancy is applied
AMOUNT PAID
Kindly collect the remaining amount if it is less than Php500
O.R. NUMBER
Date of Payment
-
Month
-
Day
Year
.
FIRE SAFETY INSPECTION CERTIFICATE
FOR CERTIFICATE OF OCCUPANCY
FOR BUSINESS PERMIT (NEW/RENEWAL)
Other
THIS CERTIFICATION IS VALID FOR
Please Select
issuance of FSIC for business permit only
issuance of FSIC for occupancy permit only
ADDRESS DESCRIPTION
ACKNOWLEDGE BY:
Name of Owner/Representative
Owner/ Representative Signature
Signature of Owner/Representative
Date
-
Month
-
Day
Year
Fire Safety Inspector(s) NAME
FSI Signature
Fire Satey Inspector
FSI Email Address
C,FSES Email Address (For Recommendation)
Preview
Submit
FOR CHIEF OF FIRE SAFETY ENFORCEMENT SECTION
Please enter verification code
CHIEF, FSES RECOMMENDATION
RECOMMEND ISSUANCE OF FSIC
RECOMMEND ISSUANCE OF NTC
Chief, FSES Signature
CFM Email Address (For Approval)
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Submit
FOR CFM/MFM (ISSUANCE OF NTC)
Please enter verification code
APPROVAL(NTC)
APPROVED
DISAPPROVED
Date of Approval(NTC)
-
Month
-
Day
Year
CFM/MFM Signature(NTC)
Preview PDF
Submit
C,FSES Email Address(NTC)
Email Address of Owner/Representative (NTC)
NTC Serial Number
NTC Serial Number Generator
NTC INVALID FSIC
*
if disapproved(ntc)
FOR CITY/MUNICIPAL FIRE MARSHAL
Please enter verification code
APPROVAL
APPROVED FSIC
DISAPPROVED FSIC
Date of Approval
-
Month
-
Day
Year
Date
CFM/MFM Signature
Preview PDF
Submit
C,FSES Email Address
Email Address of Owner/Representative
Date+1 year
-
Month
-
Day
Year
Date
FSIC Serial Number
FSIC Serial Number Generator
if disapproved
Should be Empty: