Fill - Free fillable - Biofuel Registration 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REGISTRATIONFORM

Oneregistrationformisrequiredforeachregisteringfacility.Registrationform(s)mustbesubmittedtotheWeightsandMeasuresServices

DivisionbeforeproducingorsupplyingabiofuelorbiofuelblendinArizona.ChangestothisformmustbesubmittedtotheWeightsand

MeasuresServicesDivisionnolaterthanten(10)calendardaysaftertheeffectivedateofthechange.PleaserefertoArizonaAdministrative

CodeR3‐7‐718forfurther

requirements.

SectionI.BusinessName,Address,AuthorizedAgent’sName,Telephone/FAX.



__________________________________________________________________________________________

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



______________________________________________________________________________________

BMF#ContactName  Telephone FAX



SectionII.Biofuelfacilitytype(asdefinedinA.A.C.R3‐7‐701).TheFacilitymayregisterformorethanonetype.



1) BiofuelProducer____2)BiofuelSupplier____3)BiofuelBlender____



__________________________________________________________________________________________

FacilityName Address   City StateZipCode



_________________________________________________________________________________

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



SectionIII.EPARegistrationNumber.



Ifapplicable,provideyourEPARegistrationNumberassuppliedunder40CFR80,SubpartK:



_________________________________

EPARegistrationNumber



SectionV.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.



___________________________________________________________________

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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V(continued).

StatementofConsent.



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



__________________________________________________________



Page2of2

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