Dangerous Substances (Flammable Liquids and Fuels Retail Stores) Application Form

Tosaigh (céim reatha)

Críochnaithe (gan chríochnú)

Application Details

Please choose the relevant option

First licence

Amended licence

Renewal of a licence

Transfer of a licence

Store Type

Retail Store

Kerbside Retail Store

Proposed Period of this licence (réimse éigeantach)

1 Year

2 Years

3 Years

Existing Licence No.

Applicant Details

Applicant Name (réimse éigeantach)

Applicant Address (réimse éigeantach)

Applicant Address Eircode (réimse éigeantach)

Phone Number (réimse éigeantach)

Location of the proposed retail store or current kerbside retail store

Address of the proposed retail store or current kerbside retail store (réimse éigeantach)

Premises Address Eircode (réimse éigeantach)

County (réimse éigeantach)

Townland (réimse éigeantach)

Consultant / Designer

Consultant / Designer Name (réimse éigeantach)

Consultant / Designer Address (réimse éigeantach)

Consultant/Desiger Email (réimse éigeantach)

Consultant/Designer Phone Number (réimse éigeantach)

Owner/Operator

Name of licensee/owner or operator (réimse éigeantach)

Plans

Particulars of Plans accompanying this application (réimse éigeantach)

Category or Categories of Flammable Liquids Stored

Maximum quantity of Category or Categories of flammable liquids stored or to be stored at the store:-

	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL
CATEGRORY 1	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL
CATEGRORY 2	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL
CATEGRORY 3	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL
TOTAL	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL

Other Fuels (State units measurement) e.g. Hydrogen, LPG or caged gas cylinders etc

Name of Fuel	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL
Name of Fuel	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL
Name of Fuel	Litres in Container Stores	Litres in Underground Stores	Litres in Aboveground Stores	TOTAL

Amount of fee

Proposed Period for This Licence (réimse éigeantach)

1 Year

2 Years

3 Years

Calculated Fee € (réimse éigeantach)

Administration Fee (€150) (réimse éigeantach)

Total Fee € (réimse éigeantach)

Uploaded Documentation to accompany application (PDF, GIF or JPG only)

Fee (réimse éigeantach)

Risk Assessment (PDF only) (réimse éigeantach)

Explosion Protection Document (PDF only) (réimse éigeantach)

Implementation Plan (PDF only) (réimse éigeantach)

Certificate for Electrical Inspection and Testing (PDF only) (réimse éigeantach)

Dispensing Equipment Inspection Certificate (PDF only) (réimse éigeantach)

Drawings - Site Location Map (PDF only) (réimse éigeantach)

Drawings - Hazardous Areas (PDF only) (réimse éigeantach)

Drawings - Electrical Layout (PDF only) (réimse éigeantach)

Drawings - Fuel Dispensing and Storage Infrastructure (PDF only) (réimse éigeantach)

Drawings - Standard Detals of Site Infrastructure (PDF only) (réimse éigeantach)

Additional Drawings - Optional (PDF only)

Declarations

I confirm that I have uploaded (réimse éigeantach)

Drawings

Risk Assessment

Implementation Plan

Please tick box to agree (réimse éigeantach)

I hereby certify that the information supplied above is true to the best of my knowledge and belief.

Signature of Applicant

Ainm an tSínitheora