Department of Energy
ITR Form No.:
INSPECTION / INVESTIGATION AND TESTING REPORT FORM (ITRF) — RETAILING OF LIQUID FUELS (LF)
Business & Inspection Details
Business Name:
Date of Inspection:
Dealer/Operator:
Time In & Time Out: –
Business Address:
No. of Manpower:
Start of Operation:
Retail Outlet Official:
Designation:
Special Assignment No.:
Oil Company/Trademark:
Type of Retail Outlet:
Contact No. of Owner/Manager:
Email Address:
A. Allowed To
(1) CONDUCT INSPECTION:
(2) SIGN ITRF:
B. Operational Requirements (Put ✓ if compliant, X if not compliant or n.a. if not applicable)
1.1Certificate of Compliance (COC)
1.2COC posted within business premises
2Appropriate Test Measure (Calibration Bucket)
Month & Year Calibrated: Serial No.:
3Written record/logbook of Weekly Calibration
4Outlet's Identification/Trademark
5Price Display Board (PDB)
Updated prices: same prices in dispensing pump(s)
6Research Octane Number (RON) Labels for Gasoline
7E-10 Label (contains 10% Bio-Ethanol)
8E-20 Label (contains 20% Bio-Ethanol)
9Neat Gasoline Label (contains 0% Bio-Ethanol)
10Biofuels B__ Labels for Diesel
11Non-posting of "unleaded", "lead-free"
12Consumer Safety and Informational Signs
13Diesel branding except "biodiesel"
14Not filling/dispensing in inappropriate containers
15No Drumming / "Bote-Bote" of Liquid Fuels
16Issuance of Invoice / Official Receipt
17No Hoarding
C. Facility Requirements (Put ✓ if present and X if not present), as applicable for the Type of Retail Outlet
1. Liquid Fuel Retail Outlet
1Fixed/permanent dispensing pump 6m. min. from potential source of ignition
2No open flame within 15m. minimum
35.5m. maximum length of dispensing hose
4Volume-Peso amount display up to two decimal places
5Pump Island with min. 3.5m. x 1.2m. dimension
6Lane-oriented pump with min. 0.05m. distance from fixed object
7Pump guard/column post as safety barrier
87m. minimum width each ingress & egress
96m. minimum edge to edge distance between pump islands
106m. minimum side to side distance between pump islands
11Office/Cashier's booth
124.5m minimum canopy height
13Boundary walls (concrete or cyclone fence)
14Master switch in case of emergency
15Clean restroom with water supply
16UGT has 1m. min. distance from property line and adjoining structure
17UGT with monitoring wells and fill sump (rain tight)
183.65m. minimum height of vent lines
2. Marine Retail Outlet
1Tank is petroleum compatible with corrosion-resistant bund walls
2Tank is appropriately protected with no visible mark of corrosion
3Volume-Peso amount display up to two decimal places
4Automatic shut-off nozzle
5Wharf operation or near costal/shoreline
6Fixed/permanent dispensing pump 6m. min. from potential source of ignition
7No open flame within 15m.
8Piping between dispensing and tank areas are protected against impact
9Serving exclusively for marine vessels
3. Technology-Solution Retail Outlet
11 kilometer minimum distance from existing Retail Outlet
2No other commercial establishment shall be installed/constructed within the Retail Outlet other than those necessary for its operation
3The vehicle being serviced and the delivery of the LF by the Tank Truck shall at all times be inside the business premises
41m. min. setback distance between dispensing pump and firewall
51m. min. working distance between tank truck and firewall
62000 liter maximum capacity per product
7Tank is petroleum compatible except plastic type material
8Tank is appropriately protected with no visible mark of corrosion
9Volume-Peso amount display up to two decimal places
105.5m. maximum length of dispensing hose
11Automatic shut-off nozzle
12Fixed & permanent dispensing pump 6m. min. from potential source of ignition
13No open flame within 15m.
14Piping between dispensing and tank areas are protected against impact
D. Product Details and Monitoring
Fuel / Product Premium+ E0Premium E20Premium+ E10Premium E10 Regular E10DieselDiesel +KeroseneTotal
Leave a cell blank if not applicable.
E. Supplier's Information
Supplier 1
Supplier's Name:
Date of Last Delivery:
Supplier's Address/Contact No.:
Del. Receipt/Invoice No.:
With Certificate of Fuel Quality:
Other relevant information:
Supplier 2
Supplier's Name:
Date of Last Delivery:
Supplier's Address/Contact No.:
Del. Receipt/Invoice No.:
With Certificate of Fuel Quality:
Other relevant information:
Page 1 of 2
Department of Energy
ITR Form No.:
INSPECTION / INVESTIGATION AND TESTING REPORT FORM (ITRF) — PAGE 2
F. Inventory Monitoring (Liters)
Fuel / Product Premium+ E0Premium E20Premium+ E10Premium E10 Regular E10DieselDiesel +Kerosene
G. Layout of the Retail Outlet
Lot area (m²):
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H. Verification of Calibration of Fuel Dispensers
Product PUMP Calibration Seal Status
(✓ compliant  |  X not compliant  |  n.a. not applicable)		 Calibrated By Reading (mL / 10 Liters) Results
(Passed / Tolerable / Underdelivering)
Brand Serial No. Mechanical Electronic By LGU 3rd Party
(LGU/NML)		 Fast Medium Slow Average
Yes/No Intact/
Seal		 Yes/No Intact/
Seal
I. Summary of Results of Inspection
Violation(s):
Other Observation(s):
Other Instruction(s)/Action(s):
DOE
SHOW CAUSE ORDER

You are hereby directed to SHOW CAUSE in writing and under oath, within ten (10) calendar days from receipt of this Order, why no administrative fines or penalties should be imposed and/or criminal charges should be instituted against you for the violations indicated in the Inspection Report. Submit your sworn explanation to the: The Director, Visayas Field Office, Department of Energy, 5F Escario Building, 731 Escario St., Capitol Site, Cebu City.

Further you are strictly ordered to CEASE and DESIST from operating your retail outlet until you have secured a Certificate of Compliance (COC), and to refrain from selling liquid fuels to the public or operating any fuel dispenser that is part of, results from, or is involved in the violations mentioned in the Inspection Report, and as explained to you by the DOE inspectors. The continued operation of retail outlet or fuel dispenser despite the violation(s), without implementing the required corrective measures—or unless expressly allowed by the DOE—may result in more severe penalties, including fines, further administrative action, or recommend the revocation of your business permit and closure of your retail outlet.

Furthermore, you are directed to immediately implement the corrective measures pertaining to the violations indicated in the Inspection Report, as explained to you by the DOE inspectors, and to submit proof of compliance to the DOE within ten (10) calendar days from receipt of this Order. Compliance of this Directive shall be without prejudice to any fines, penalties or legal action that the DOE may impose or initiate against you.

CONFORME:

I hereby certify that the inspection in this retail outlet was conducted in my presence and under the authority of the owner/operator hereof. I further certify that I have read this entire Inspection/Investigation Testing Report and I attest that all the foregoing statements/information written herein have been thoroughly explained to me and are true and correct.

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