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    TSRO Undertaking Form

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    De'Luna Law
    This document is an affidavit of undertaking for a certificate of compliance for a technology solution retail outlet. It details the requirements that must be met including only installing the outlet to address local fuel needs, maintaining a 1km distance from other outlets, complying with guidelines, and assuming responsibility for any issues. The affiant commits to strictly following the requirements and understands non-compliance could result in penalties including suspension or closure.

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    © All Rights Reserved
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    TSRO Undertaking Form

    Uploaded by

    De'Luna Law
    79 views1 page
    This document is an affidavit of undertaking for a certificate of compliance for a technology solution retail outlet. It details the requirements that must be met including only installing the outlet to address local fuel needs, maintaining a 1km distance from other outlets, complying with guidelines, and assuming responsibility for any issues. The affiant commits to strictly following the requirements and understands non-compliance could result in penalties including suspension or closure.

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    This document is an affidavit of undertaking for a certificate of compliance for a technology solution retail outlet. It details the requirements that must be met including only installing the outlet to address local fuel needs, maintaining a 1km distance from other outlets, complying with guidelines, and assuming responsibility for any issues. The affiant commits to strictly following the requirements and understands non-compliance could result in penalties including suspension or closure.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    79 views1 page

    TSRO Undertaking Form

    Uploaded by

    De'Luna Law
    This document is an affidavit of undertaking for a certificate of compliance for a technology solution retail outlet. It details the requirements that must be met including only installing the outlet to address local fuel needs, maintaining a 1km distance from other outlets, complying with guidelines, and assuming responsibility for any issues. The affiant commits to strictly following the requirements and understands non-compliance could result in penalties including suspension or closure.

    Copyright:

    © All Rights Reserved
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    DOE FORM – UNDERTAKING.

    TSRO OIMB/COR#035-
    COCD

    AFFIDAVIT OF UNDERTAKING FOR CERTIFICATE OF COMPLIANCE


    OF TECHNOLOGY SOLUTION RETAIL OUTLET

    ESTELLA V. PANGO
    I, ___________________________________________________ with residential address at
    (Name)
    LOWER DICAYAS, DIPOLOG CITY
    ______________________________________________ under oath, hereby depose and state THAT;
    (Address)

    1.
    VEZPA FUEL REFILLING STATION
    I am the owner/authorized representative of ___________________________________,
    (Business Name)
    as authorized under Board Resolution No. _____________ dated _____________ with DTI/SEC/CDA
    3991996
    Registration No. _____________, Business Permit No. _____________ and office address at
    NEW DAPITAN, RIZAL, ZAMBO. DEL NORTE
    ___________________________________________;
    (Business Address)

    2. Pursuant to Section 15 (b), Rule of Department Circular (DC) No. 2017-11-0011,


    otherwise known as the “Revised Retail Rules”, I hereby commit to strictly comply with the following
    requirements provided for by said circular for a Certificate of Compliance (COC), except provisions
    which are incompatible with the Technology Solution Retail Outlet (TSRO), e.g., Rule II Sec. 4 (c),
    Sec. 6 (b.2), Rule III Sec. 11 (a), (b), (c) and (e), 12, 13, 14 (b), Sec. 15 (a) and (c), Rule VIII Sec.
    29 A (2), (3), (4b):

    a. Ensure that the installation of the TSRO is for the purpose of addressing the fuel
    requirements of those catered by the “bote-bote” retailing in the area applied for;
    b. Ensure a distance of one (1) kilometer radius from other existing Retail Outlet;
    c. Ensure that no other commercial establishment shall be installed/constructed within
    the TSRO other than those necessary for its operation;
    d. Ensure that the vehicle being serviced and the delivery of the Liquid Fuels by the Tank
    Truck shall at all times be inside the business premises;
    e. Maintain one (1) meter set back distance in the cashier’s booth or dispensing pump to
    firewall;
    f. Maintain one (1) meter working distance from Tank Truck to firewall;
    g. Comply with the guidelines set in the Addendum to Rule IV of the said circular;

    3. My non-compliance with the above duties/responsibilities shall give the Department of


    Energy the right to issue suspension of operation or closure order, other applicable
    penalties under existing rules and regulations and recommendation to the LGU for the
    suspension or revocation of business permit;

    4. I have read the contents and the facts stated herein are true and correct based on my
    personal knowledge;

    5. I likewise UNDERTAKE and ASSUME full and complete responsibility for all consequences
    which may arise in connection with said registration/application; and

    6. I am executing this affidavit in compliance with the requirements for the issuance of COC
    pursuant to the said department circular.

    IN WITNESS WHEREOF, I hereby set my hand this _______of day __________________ in


    ______________________________.
    ESTELLA V. PANGO
    ______________________________
    Affiant

    SUBSCRIBED AND SWORN to before me this ____ day of ___________ at _____________.


    Sec. of State - Illinois
    Driver’s License ID No. P520-2185-9966 issued at _______________
    Affiant having exhibited to me his/her____________________________
    (Government ID)
    valid until 12/20/2024
    on _________________.

    Doc. No.: ________


    Page No.: ________ NOTARY PUBLIC
    Book No.: ________
    Series of _________

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