DOE-VFO | ITR Form

ITR Form No.:

INSPECTION / INVESTIGATION AND TESTING REPORT FORM (ITRF) — PAGE 2

G. Layout of the Retail Outlet

Lot area (m²):

With electric vehicle charging facility (✓ if available)

Tap to take a photo of the layout / sketch

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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
	Brand	Serial No.	Yes/No	Intact/ Seal	Yes/No	Intact/ Seal	By LGU	3rd Party (LGU/NML)	Fast	Medium	Slow	Average

Remarks

I. Summary of Results of Inspection

Violation(s):

Other Observation(s):

Other Instruction(s)/Action(s):

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.

Printed Name of DOE Representative/Inspector

Printed Name of Witness

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.

Printed Name of Retail Outlet Official