Department of Environment and Natural Resources

Envirnmental Management Bureau

1ST QUARTER 2019 (JANUARY-MARCH 2019) Reference No:

(to be filled up by DENR only)

GENERAL INFORMATION SHEET

Name of the
Establishment/Facility
GMI SHELL GASOLINE STATION
Establishment/Facility Street# & Street Name:______________________________
Address Barangay:____________________City/Municipality:___________________
(NOT the company of head Province: _______________________
office)
Name of MRS. EMERITA C. GALLINERO
Owner Company
Address Street# & Street Name:______________________________
(if address is not the same as Barangay:____________________City/Municipality:___________________
previous address) Province: _______________________

Phone Number 0906-6091501 Fax Number

e-mail address NONE
Philippine Standard Industry Classification Code No. _________________
Type of Business/ Philippine Standard Industry Descriptor: ___________________________
Industry Classification

Responsible Officer/s:
CEO/President:__________________________________
Tel.#:_____________________ Fax #:___ ___________
e-mail address:_______________________________________
Plant Manager: _______________________________________
Tel.#:_____________________ Fax #:___ ___________
e-mail address:_______________________________________

Name:_______________________________________________
Pollution Control Tel.#:_____________________ Fax #:___ ___________
Officer e-mail address:_______________________________________

single proprietorship partnership

Legal Classification private domestic corporation government corporation
Multi-national ______________________________

We hereby certify that the above information are true and correct.

EMERITA C. GALLINERO ANTHONY C. GALLINERO

Name/Signature of CEO/President Name/Signature of PCO
d correct.