FORM C

(See Rules 49, 54 and 55)

Application for the grant / amendment / renewal of a licence to fill and / or store
compressed gas in cylinders. (Documents overleaf must be enclosed with this application, it is
for the grant of a licence in Form E, F & G
------------------------------------------------------------------------------------------------------------------------------1. Name in which licence is required
: MRS. PRATIBHA MAHAVEER DANIGOND,
AND MR. PUSHPADANT MAHAVEER DANIGOND

PARTNERS,
M/s PADMA INDANE GAS SERVICE, TERDAL

Applicants calling
Applicants full postal address

: M/s Padma Indane Gas Service

: M/S PADMA INDANE GAS SERVICE,
INDANE GAS DISTRIBUTORS, PADMA NAGAR
TERDAL, JAMKHANDI TALUK, BAGALKOT DIST.
PIN 587315. Karnataka State.

2. Situation of the premises where compressed

gas is to be stored / filled
State
District
Town or Village
Survey No & Name of the road
Nearest Police Station
Nearest Railway Station

: Karnataka
: Bagalkot
: Terdal (V), Jamkhandi Taluk
: Ward No. 5/563, Padma Nagar, Terdal Town
: Terdal
: Kudachi

3. Nature of each compressed gas proposed to be

filled / stored namely
(a ) Toxic
(b) Non toxic and non flammable
(c) Non toxic & flammable
(d) Dissolved Acetylene Gas
(e) Non toxic & flammable liquefiable
gas other than LPG
(f) Liquefied Petroleum Gas
4.
5.

6.
7.

: Liquefied Petroleum Gas

Chemical name of each compressed

gas proposed to be filled / stored

: Butane & Propane mixture (LPG)

Quantity of each compressed gas proposed

to be filled / stored in terms of numbers for
gases mentioned under items 3(a), 3(b), 3(c)
or 3(d); and in terms of Kgs. for gases men-tioned under items 3(e) or 3(f)

: 12000 Kg. of LPG

Nature, Chemical name & quantity of each

compressed gas already filled / stored in :
the premises
Number of the licence held for the
premises and the full name of the
holder of the licence.

: LPG
:
: G/SC/KA/06/483 (G5027)
: Mrs. Pratibha Mahaveer Danigond,
and Mr. Pushpadant Mahaveer Danigond
Partners, M/s Padma Indane Gas Service,
Padma Nagar, Terdal, Jamkhandi Taluk,
Bagalkot dist. Pin - 587315

I hereby declare that the statements made above have been checked up by me and are
true and I undertake to abide by the norms and conditions of the licence, which will be granted
to me.
Date : 25.07.2012

Mrs. Pratibha M. Danigond

Mr. Pushpadant M. Danigond
(Signature & designation of the applicants)
Partners

Mandya
Date: 25.07.2012
To
The Dy. Chief Controller of Explosives
Mangalore
Sub:
Ref:

Change of licence status from Proprietorship to Partnership of M/s Padma Indane

Gas Service, Padma Nagar, Terdal, Jamkhandi Taluk, Bagalkot Dist.- Transfer /
Amendment of licence reg.
Licence No. G/SC/KA/06/483 (G5027) and premises located at Ward No. 5/563,
Padma Nagar, Terdal Town, Bagalkot Dist.

Sir,
We are having LPG cylinder storage shed at Ward No. 5/563, Padma Nagar, Terdal Town,
Bagalkot Dist. with name M/s Padama Indane Gas Service, Terdal, Bagalkot Dist. in the name of
Rajandra Mallappa Danigond, Proprietor. Proprietor of M/s was demised/
expired (copy of death certificate enclosed); after that we approached M/s HPC Limited for
change of dealership our name. They have considered our request and restored supply of
cylinders to our godown as per revised partnership deed and issued dealership agreement..
Recently we have constituted a partnership with Mrs. PRATIBHA MAHAVEER
DANIGOND, AND MR. PUSHPADANT MAHAVEER DANIGOND as Partners, M/s Padma
Indane Gas Service and also got the revised dealership agreement from M/s HPCL, Bangalore
incorporating names of partners. Now we are submitting revised documents for amendment of
license towards change of status from proprietorship to Partnership of our LPG cylinder storage
shed located at Terdal, Bagalkot Dist. We are submitting the following documents for transfer/
amendment and renewal of licence:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Form C duly filled and signed by the applicant

Original explosive licence with approved plan
4 copies of as built drawings showing partners names/ M/s Prasanna Gas
.
DD for Rs. 500/- in favour of Joint Chief Controller of Explosives payable at
Chennai (fee for amendment/ transfer)
Copy of Partnership Deed
Land documents / lease deed
List of partners and their specimen signatures
Authorization to Mr. . to sign the papers
Dealership Agreement with M/s HPC Ltd.

Kindly consider our application for amendment/ transfer of licence and also change the
status from proprietorship to partnership.
Thanking you,
Yours faithfully,
(Mrs. Pratibha Mahaveer Danigond)
M/s Padma Indane Gas Service
Partner

ON LETTER HEAD
AUTHORISATION

WE

hereby by authorize Mrs. Pratibha Mahaveer Danigond, Partner M/s

Padma Indane Gas Service, Terdal, Bagalkot Dist. to sign all the papers to
correspond with your organization i.e. Petroleum Explosives Safety
Organisation from time to time.
This is for your kind information.
1. Mr. Pushpadant Mahaveer Danigond Partner, _______________
M/s Padma Indane Gas Service
(signature)

(Mrs. Pratibha Mahaveer Danigond)

M/s Padma Indane Gas Service
Partner

PADMA INDANE GAS SERVICE

INDANE GAS DISTRIBUTORS,
Padma Nagar, Terdal, Jamkhandi Taluk,Bagalkot Dist. 587315. Karnataka state.

List of partners & their specimen signatures

S.No.
1.

Name

Signature

2.
3.

(Mrs. Pratibha Mahaveer Danigond)

M/s Padma Indane Gas Service
Partner/Managing Partner