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
__________________________________________
ARIZONABIOFUELREGISTRATIONFORM
Oneregistrationformisrequiredforeachregisteringfacility.Registrationform(s)mustbesubmittedtotheWeightsandMeasuresServices
DivisionbeforeproducingorsupplyingabiofuelorbiofuelblendinArizona.ChangestothisformmustbesubmittedtotheWeightsand
MeasuresServicesDivisionnolaterthanten(10)calendardaysaftertheeffectivedateofthechange.PleaserefertoArizonaAdministrative
CodeR37718forfurther
requirements.
SectionI.BusinessName,Address,AuthorizedAgent’sName,Telephone/FAX.
__________________________________________________________________________________________
BusinessName Address City StateZipCode
______________________________________________________________________________________
BMF#ContactName Telephone FAX
SectionII.Biofuelfacilitytype(asdefinedinA.A.C.R37701).TheFacilitymayregisterformorethanonetype.
1) BiofuelProducer____2)BiofuelSupplier____3)BiofuelBlender____
__________________________________________________________________________________________
FacilityName Address City StateZipCode
_________________________________________________________________________________
ContactName Telephone FAX
SectionIII.EPARegistrationNumber.
Ifapplicable,provideyourEPARegistrationNumberassuppliedunder40CFR80,SubpartK:
_________________________________
EPARegistrationNumber
SectionV.StatementofConsent.
IherebycertifyandattestthatIhavetheauthoritytoactonbehalfandbind
________________________________________(BusinessName),andthattheinformationprovidedistrueand
accuratetothebestofmyknowledge.
___________________________________________________________________
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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
___________________________________________________________________
SectionV(continued).
StatementofConsent.
Onbehalfof________________________________________(BusinessName),Iherebyprovideconsenttothe
WeightsandMeasuresServicesDivisionoritsauthorizedagenttocollectsamplesandassessdocumentation
andrecordsasprovidedinArizonaAdministrativeCodeR37718.Iagreethatchangestoanyinformation
providedinthisregistrationformwillbe
senttotheAssociateDirectoroftheWeightsandMeasuresServices
Divisionnolaterthanten(10)calendardaysaftertheeffectivedateofthechange.
____________________________________________________________________________
Signature PrintedName 
______________________________________________________________________________
Position BusinessName Date
__________________________________________________________
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