XLS《首页》

"燃气经营许可证申请表" "企业名称(章):" "填表日期:年月日" "

一、基本情况",,

,,

,,

,,

,,

,,

"企业名称",,

,,

,,

"注册地址",,

,,

"邮政编码",,

"成立时间",,

,,

"营业执照注册号",,

"联系电话",,

,,

"传真",,

"企业网址",,

,,

"电子邮箱",,

"法定代表人",,

"职务",,

,"职称", "主要负责人",,

,,

,,

"安全负责人",,

,,

,,

"技术负责人",,

,,

,,

"企业注册资本",,

,"万元",,

, "企业类型",,

,,

,,

"经营范围",,

,,

,,

"供气区域",,

,,

,,

"服务电话",,

,"抢险电话",,

, "企业简介:",,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

"

二、股东以及股权结构登记表",,

,,

"序号","企业股东名称","股份所占比例" ,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, "

三、从业人员状况登记表",,

,,

, ,,

,,

, "从业人员总数",,

"管理人员",,

, "类别","层级","数量(名)",,

"备注", "学历教育","硕士以上",,

,,

,"大学本科",,

,,

,"大学专科",,

,,

,"合计",,

,,

"专业技术人员","高级",,

,,

,"中级",,

,,

,"初级",,

,,

,"合计",,

,,

"安全管理人员","注册安全工程师",,

,,

,"持有《危险物品生产经营、储存单位主要负责人证》",,

,,

,"持有《危险物品生产经营、储存单位安全生产管理人员证》",,

,,

,"持有《燃气经营企业从业人员专业培训考核合格证书》",,

,,

,"合计",,

,,

"运行、维护或抢修人员","管道巡检工",,

,,

,"安检员",,

,,

,"灌装工",,

,,

,"送气工",,

,,

,"电工",,

,,

,"抢险抢修人员",,

,,

,"客服人员",,

,,

,"燃气组分检测装置操作工",,

,,

,"合计",,

,,

"主要安全、技术管理人员状况",,

,,

, "姓名","身份证号码","职务","任职资格","证书编号","发证机关" ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, "

四、燃气抢险设施登记表",,

,,

, ,,

,,

, "抢险队名称",,

,,

, "负责人",,

,"电话",,

"抢险队人数",,

,"抢险车辆(辆)",,

"燃气抢险点一览表",,

,,

, "序号","名称",,

"地址",,

"电话" ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, "燃气抢险设备一览表",,

,,

, "序号","名称",,

"规格型号",,

"数量" ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, "

五、燃气设施登记表",,

, ,,

, "燃气设施情况","设施名称","数量(座)","备注" ,"人工煤气生产厂",,

,"储配站",,

,"门站",,

,"气化站",,

,"混气站",,

,"加气站",,

,"灌装站",,

,"供应站",,

,"调压站",,

,"管道气营业点",,

"燃气设施一览表",,

, "序号","名称","地址","设施类别" ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, "

六、燃气接收站、储配站、汽车加气站登记表" "设施名称",,

,,

,,

, "设施地址",,

,,

,,

, "主要负责人",,

,,

"安全负责人",,

, "联系电话",,

,,

"传真",,

, "营业执照注册号",,

,,

"消防验收文号",,

, "竣工验收日期",,

,,

"工程造价",,

, "用地种类",,

,,

"占地面积",,

"平方米", "储罐资料",,

"安装形式",,

,"储罐数量",,

,,

"储罐总容积","立方米",,

"单罐最大容积",,

"立方米" "主要设备",,

"项目名称","型号",,

"数量(台)",,

"备用数(台)" ,,

"罐装设备",,

,,

, ,,

"胫泵",,

,,

, ,,

"压缩机",,

,,

, ,,

"危运IC卡系统",,

,,

, ,,

"视频监控系统",,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, "人员配备情况","姓名","年龄","岗位","岗位技能证书及编号",,

"发证机关", ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, ,,

,,

,,

, "

七、瓶装燃气供应站登记表",,

,,

, ,,

,,

, "供应站名称",,

,,

, "供应站地址",,

,,

, "主要负责人",,

,,

"安全负责人", "联系电话",,

,,

"传真", "营业执照注册号",,

,,

"消防验收文号", "供应站等级",,

,,

"占地面积","平方米" "场所产权人",,

,,

"租赁合同备案号", "人员配备情况","姓名","年龄","岗位","岗位技能证书及编号","发证机关" ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, ,,

,,

, "

八、企业申报材料目录",,

,,

, ,,

, "序号","材料名称","页数","备注" ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,,

, ,"企业法定代表人申明","本人(法定代表人)(身份证号码)郑重声明,此次填报的《燃气经营许可证申请表》及附件材料、数据、内容是真实的,如有虚假,本人及本企业愿接受燃气行政主管部门及其他有关部门依据法律法规给予的处罚.

" ,,

,,

,,

,,

"企业法定代表人:(签名)(盖章)" ,,

"" ,,

"年月日" ,,

"" ,"所在县(区)主管部门意见", ,,

,,

,,

"(盖章)" ,,

"" ,,

"年月日" ,,

,"审批机关意见", ,,

,,

,,

"(盖章)" ,,

"" ,,

"年月日" ,,

,"备注:",