IRAC503(2010)
LICENSE FEES PAYABLE TO “ISLAND REGULATORY AND APPEALS COMMISSION”
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.
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.
National Bank Tower
501-134 Kent Street
P.O. Box 577
Charlottetown, PE
C1A 7L1
APPLICATION FOR RETAIL
PETROLEUM OUTLET LICENSE
RETAIL OUTLET RENEWAL
ALL APPLICABLE QUESTIONS MUST BE ANSWERED
1 1
NAME OF OUTLET: NAME OF OUTLET:
2
LOCATED AT: (Street) (Town, Community) (Province) (Postal Code)
P.E.I.
3
TELEPHONE NUMBER:
4
FAX NUMBER:
5
a) OWNER OF OUTLET:
b) OWNER’S MAILING ADDRESS:
6
a) OPERATOR OF OUTLET:
b) OPERATOR’S MAILING ADDRESS:
7
CURRENT LICENSE NUMBER:
8
HOURS OF OPERATION FOR MOTOR FUELS DISPENSING:
Full-Serve a.m. to p.m. Self-Serve a.m. to p.m.
9
METHOD OF DISPENSING (check all that apply):
Full-serve Split-serve Self-serve Keylock Cardlock
10
DESCRIBE OTHER SERVICES PROVIDED AT THIS OUTLET (service bays, c-store/general store, restaurant, etc.):
11
PETROLEUM PRODUCTS SOLD: (A SEPARATE FORM IS REQUIRED FOR EACH LICENSE AT MARINE OUTLETS)
Gasoline Clear Diesel Fuel Marked Diesel Fuel Propane Kerosene Furnace
12
PROPANE: Automotive Filling of up to 20 kg. cylinders 9.09 kg Exchange Centre
Storage & Sale of up to 45.4 kg Cylinders Filling, Storage & Sale of up to 45.4 kg Cylinders
13
WHICH OIL COMPANY IS YOUR SUPPLIER (INCLUDING PROPANE):
14 ARE BAY SERVICES AVAILABLE:
Yes No
15
VOLUME (IN LITRES) SOLD JAN. 1
ST
TO DEC. 31
ST
LAST YEAR?
Full-Serve
Self-Serve
Gasoline
Diesel
Propane
Kerosene
Furnace
16 STORAGE CAPACITY:
Gasoline litres
Diesel litres
Propane litres
Kerosene litres
Furnace litres
17
IS THIS OUTLET PRESENTLY IN OPERATION: YES NO (State reason and expected date of re-opening)
18 NUMBER OF PUMPS:
Single Double Triple
19
TOTAL NUMBER OF NOZZLES:
20
HAVE THERE BEEN ANY CHANGES IN PUMPS OR STORAGE EQUIPMENT SINCE YOUR LAST LICENSE WAS ISSUED:
NO YES (Provide Details/Serial Numbers)
21
WHAT ARE YOUR CURRENT SELLING PRICES PER LITRE OF THE FOLLOWING PRODUCTS:
FULL-SERVE
SELF-SERVE
Regular Unleaded Gasoline
Carburation Propane
Mid-grade Unleaded Gasoline
Propane in Cylinders
Premium Unleaded Gasoline
Kerosene
Diesel Fuel
Furnace
22
I HEREBY DECLARE THAT THE ANSWERS MADE TO THE ABOVE QUESTIONS ARE TRUE AND, IF A LICENSE IS ISSUED, I UNDERTAKE TO
CARRY OUT IN EVERY MANNER THE REQUIREMENTS OF THE PETROLEUM PRODUCTS ACT & REGULATIONS.
SIGNATURE: CORPORATE NAME:
PRINT NAME: _____________________
(Please check) Owner Lessee Agent
TELEPHONE:
EMAIL:
TITLE:
DATE:
