Form A-3609-Mf - Field Inspection Report

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A-3609-MF
STATE OF NEW JERSEY
6-96, R-1
Division of Taxation
MOTOR FUELS BRANCH
FIELD INSPECTION REPORT
(609) 984-7171
TELEPHONE
Security Sealing of Diesel Fuel Dispensing Pump Totalizer.
(609) 984-7171
Registered Name: ____________________________________________
Date: _________________________________________
Address:____________________________________________________
Seller/User Lic #________________________________
___________________________________________________________
Retail Dealer Lic #_______________________________
___________________________________________________________
FID # _________________________________________
Phone:________________________________________
Number of Diesel Storage Tanks_________________________________
Total Storage Tank Capacity ____________________________________
Taxpayer Representative’s:
Suppliers: ___________________________________________________
Name:________________________________________
____________________________________________________________
Title: _________________________________________
____________________________________________________________
Pump
Pump Serial
Pump Totalizer
Epoxy
Number
Number
Reading
Applied
Checked
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
I acknowledge that the Pump Totalizer readings as listed are correct. I further acknowledge that whenever these totalizers are removed, replaced, or repaired it shall be reported
to the Motor Fuels Branch within seven (7) days. I further acknowledge that I have been provided with a copy of this inspection report and instructions to comply with this mandate.
____________________________________________
Taxpayer Representative (Print Name)
Date
_________________________________________________
____________________________________________
Investigator’s Signature
Date
Representative Signature
Date

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