Ministry of Industries Department of Explosive Explosive License No TP-66/CNG/2773 (06/06/2012)

M/s

Sub: Annual 3 rd Party Inspection of M/s .

Address: _____________________________________________________________________________ ________

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Contact Person:_______________________, Phone:_____________________, Mobile:__________________

Explosive Ref.no. : ____________________________________________________.

URS Ref.no. : ____________________________________________________.

Date of Inspection : ____________________________________________________.

Type of Inspection: ____________________________________________________.

CNG Station is operational since:____________________________________________.

At the request of Explosive Dept undersigned inspection engineer to URS inspection acting within the General conditions of Code of Practice of CNG Rules 1992, Mines and mineral safety rules 2010 attended the Annual /Amendment inspection of CNG Station.

Following deficiencies were noted in station:_________________________________________________________________________________________________

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Parameters Check:________________________________________________________________________________________________

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Ministry of Industries Department of Explosive Explosive License No TP-66/CNG/2773 (06/06/2012)

Following documents not provided at the time of inspection:_________________________________________________________________________________________________

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Recommendations:_________________________________________________________________________________________________

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Conclusion:_________________________________________________________________________________________________

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Note:i). The rectifications / remedial measures in respect of above mention deficiencies were explained by URS inspection

team and fully understood by the undersigned.(Station Representative)

ii). Compliance of rectification of above mentioned deficiencies should be submitted to Explosive & URS Inspection.iii.) Report will be forwarded subject to the review of Documents.

Surveyor to URS Inspection Pvt Ltd Owner/Managing Director/Partner to CNG Station

Name: Name:

Date: Date:

Time: Time: