Fill - Free fillable - Biofuel Annual Report Form (Arizona) PDF form

Weights and Measures Services Division

1688 W. Adams Street, Phoenix, Arizona 85007

Metrology Laboratory: 4425 W. Olive Avenue, Glendale, AZ 85302

(602) 542-4373 FAX: (623) 939-8586 agriculture.az.gov



DOUGLAS A. DUCEY

Governor

MARK W. KILLIAN

Director

__________________________________________

ARIZONABIOFUELANNUALREPORTFORM

OneannualreportformmaybesubmittedformultipleBMF’s(locations)thatoperateunderthesamecompany.Theannualreportform

mustbesubmittedtotheWeightsandMeasuresServicesDivisionbyJanuary30

ofeachyearforthepreviouscalendaryear.Pleasereferto

ArizonaAdministrativeCodeR3‐7‐718forfurtherrequirements.

SectionI.BusinessName,Address,ContactName,Telephone/FAX.



__________________________________________________________________________________________

BusinessName Address   City StateZipCode



___________________________________________________________________________________________ 

ContactName Telephone  FAX



SectionII.Listthetotalvolumeforeachbiofueltypeblended,produced,orsuppliedbyeachBMFinthetablebelow.

Anexamplehasbeenprovidedonthefirstlineforyourreference.



ReportingYear:20____



BMF# BiofuelType TotalVolume

(Pleasenoteifvolumeisingalorbbl)

EXAMPLE23456 EXAMPLE B‐10 EXAMPLE25,000gal

 



 



 



 



 



 



 



=

__________________________________________________________

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Weights and Measures Services Division

1688 W. Adams Street, Phoenix, Arizona 85007

Metrology Laboratory: 4425 W. Olive Avenue, Glendale, AZ 85302

(602) 542-4373 FAX: (623) 939-8586 agriculture.az.gov



DOUGLAS A. DUCEY

Governor

MARK W. KILLIAN

Director



___________________________________________________________________

SectionIV.StatementofConsent.



IherebycertifyandattestthatIhavetheauthoritytoactonbehalfandbind



________________________________________(BusinessName),andthattheinformationprovidedistrueand

accuratetothebestofmyknowledge.



Onbehalfof________________________________________(BusinessName),Iherebyprovideconsenttothe

WeightsandMeasuresServicesDivisionoritsauthorizedagenttocollectsamplesandassessdocumentation

andrecordsasprovidedinArizonaAdministrativeCodeR3‐7‐718.Iagreethatchangestoanyinformation

providedinthisregistrationformwillbe

senttotheAssociateDirectoroftheWeightsandMeasuresServices

Divisionnolaterthanten(10)calendardaysaftertheeffectivedateofthechange.



____________________________________________________________________________

Signature   PrintedName   



______________________________________________________________________________

Position    BusinessName   Date



Please

submitthisformtotheDivisionbye‐mailatdwm@azda.gov,orbyfaxat(623)939‐8586.

__________________________________________________________

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