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A V M U S E G H (Prince Edward Island Regulatory & Appeals Commission)

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Country of origin: CANADA
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THIS APPLICATION IS FOR A CHANGE IN (check all that apply):
1. METHOD OF DISPENSING
2. OPERATOR
3. SUPPLIER
4. PETROLEUM PRODUCTS OFFERED
5 DISPENSING EQUIPMENT
6. PETROLEUM STORAGE
7. HOURS OF DISPENSING
8. OTHER
ALL APPLICABLE QUESTIONS MUST BE ANSWERED
1
NAME OF OUTLET:
2
LOCATED AT: (Street) (Town, Community) (Province) (Postal Code)
P.E.I.
3
CURRENT LICENSE NUMBER:
4
5
FAX NO:
6
OWNER OF OUTLET:
7
OWNER’S MAILING ADDRESS:
8
OPERATOR OF OUTLET:
9
OPERATOR’S MAILING ADDRESS:
10
SUPPLIER OF PETROLEUM PRODUCTS (INCLUDE PROPANE SUPPLIER, IF APPLICABLE):
11
METHOD OF DISPENSING (check all that apply):
Full-serve Split-serve Self-serve Keylock Cardlock
(An attachment outlining the reasons for any proposed change must accompany this form)
12
TYPE OF OUTLET:
Service Station C-Store/General Store Marine Propane Other ___________________
13
DESCRIBE OTHER SERVICES TO BE PROVIDED AT THIS OUTLET: (Plans of any proposed changes must
accompany this application)
14
PRODUCTS TO BE DISPENSED (OTHER THAN MARINE):
Regular Gasoline Mid-Grade Gasoline Premium Gasoline Diesel
Propane Furnace Fuel Other
15
MARINE ONLY (SEPARATE FORM FOR EACH LICENSE):
Marked Diesel Fuel Clear Gasoline Clear Diesel Fuel Other_________ _
16
NUMBER OF AUTOMOTIVE SERVICE BAYS IN
OPERATION AT THIS OUTLET:
17
WHEN ARE BAY SERVICES AVAILABLE:
a.m. to p.m.
18
HOURS OF OPERATION FOR MOTOR FUELS DISPENSING:
Full Serve a.m. to p.m. Self Serve a.m. to p.m.
19
IS OUTLET PRESENTLY IN OPERATION: YES NO (State reason and expected date of re-opening)
PAGE 1 OF 2
National Bank Tower
501-134 Kent Street
P.O. Box 577
Charlottetown, PE
C1A 7L1
Clear Form
20
OUTLINE ANY PROPOSED CHANGES TO PUMPS AND STORAGE EQUIPMENT: (Plans of any proposed changes
must accompany this application. Approval must be obtained from the Department of Agriculture and Land before any
changes are made which involve petroleum storage.)
21
GIVE DETAILS OF ANY PROPOSED CHANGES TO WASHROOMS:
22
PROPOSED COMPLETION DATE OF ANY ALTERATIONS:
23
I HEREBY DECLARE THAT THE ANSWERS MADE TO THE ABOVE QUESTIONS ARE TRUE AND, IF APPROVAL IS
GRANTED BY THE COMMISSION, I UNDERTAKE TO CARRY OUT IN EVERY MANNER THE REQUIREMENTS OF
THE PETROLEUM PRODUCTS ACT AND REGULATIONS.
CORPORATE
SIGNATURE: NAME:
PRINT NAME: _____________________ TELEPHONE:
(Please check) Owner Lessee Agent
TITLE: DATE:
PLEASE NOTE:
ALTERNATIONS ARE NOT TO BE COMMENCED UNTIL AUTHORIZATION IS RECEIVED FROM THIS COMMISSION.
IN THE CASE OF A CHANGE OF OPERATOR OR A CHANGE IN PETROLEUM SUPPLIER, A COPY OF THE SUPPLY
AGREEMENT MUST ACCOMPANY THE APPLICATION. THIS IS NOT REQUIRED FOR A CHANGE IN MANAGER ONLY.
IN THE CASE OF A CHANGE OF OWNER OF AN OUTLET, PROOF OF OWNERSHIP MUST ACCOMPANY THE
APPLICATION (SUCH AS A COPY OF THE DEED OR AGREEMENT OF PURCHASE AND SALE).
A FEE AS OUTLINED IN THE CURRENT LICENSE FEE SECTION FOUND ON THE COMMISSION’S PUBLIC WEBSITE
WILL BE PAYABLE TO THE ISLAND REGULATORY AND APPEALS COMMISSION WHERE A LICENSE AMENDMENT IS
REQUIRED.
Information on this Form is collected pursuant to the Petroleum Products Act and will be used by the Commission in the administration of the
said Act. For additional information, contact the Commission at 902-892-3501 or by email at info@irac.pe.ca.
IRAC509(20)
PAGE 2 of 2
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A V M U S E G H (Prince Edward Island Regulatory & Appeals Commission)

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Completed 24 July 2021

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