Form Ppi 11 - Application For Petroleum Equipment Repairmans License - 1997

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MISSISSIPPI DEPARTMENT OF AGRICULTURE AND COMMERCE
PETROLEUM PRODUCTS INSPECTION DIVISION
P. O. BOX 1609
JACKSON, MISSISSIPPI 39215-1609
APPLICATION FOR PETROLEUM EQUIPMENT REPAIRMANS LICENSE
I hereby make application for a license to remove seals, service, adjust, repair and replace seals on
gasoline pumps, meters and devices used to dispense petroleum products as provided by the
Petroleum Products Inspection Law of the State of Mississippi and regulations adopted thereunder.
Date:
19
Name:
Address:
City, State, Zip:
Phone:
Fax Telephone:
Company Represented:
Company Address:
City, State, Zip:
Phone:
Fax Telephone:
1. Training and Experience:
2. Petroleum Equipment Qualified to Service:
3. Service to Be Performed:
4. Size and Type Calibrated Test Measure(s) or Provers Possessed:
5. Date Testing Equipment Calibrated:
6. By Whom:
7. Address:
PPI NO. 11
Over
0664 REV. 4-97

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