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Application Form
LLDA application form for barging clearance
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: LAGUNA LAKE DEVELOPMENT AUTHORITY
National Ecology Center, East Avenue
Diliman, Quezon City
Tel. Nos.: 332-2346, 376-4039, 376-4072, 376-4049, 376-4061
APPLICATION FOR BARGING CLEARANCE
Barging of Petroleum & Petroleum Based Products
in Laguna de Bay & Napindan Channel
_________________________________________________________________________________
INFORMATION ON THE APPLICANT
Nature of Application:
new
renewal
Name of Vessel : _____________________________________
Type of Vessel :
Motorized barge
Dumb barge
Tugboat
Name of Barger
: _____________________________________
Tel. No.
Fax No.
E-mail
Address of Barger
: _____________________________________
________
________
_______
Name of Charterer
: _____________________________________
Tel. No.
Fax No.
E-mail
Address of Charterer
: _____________________________________
________
________
_______
VESSEL FEATURES
Hull Type ______________________
Builder ________________________
Length ______ (m)
Seal of Hatches __________
Year Built _________
Place Built __________________
Breadth _________ (m) Depth _______ (m)
Compartment
______________
Capacity (liters)
___________
______________
___________
______________
___________
______________
___________
______________
___________
______________
___________
______________
___________
TOTAL CAPACITY
Calibrated by
Date Calibrated
: ____________________________
: ____________________________
:_____________________________
I hereby certify and declare under pain of perjury that the information contained herein is true, correct,
complete and accurate to the best of my personal knowledge.
____________________________
Signature Over Printed Name
of Authorized Representative
_______________________________
Date Signed
LLDA-CPD-Form 24
Issue Date: April 2015
Issue No.: 01
