Form 0840 V1 - Affidavit Of Inspection Of Lpg Bulk Tank

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SD EForm - 0840
V1
HELP
Complete and use the button at the end to print for mailing.
Affidavit of Inspection of LPG Bulk Tank
Reference SDCL 10-47B-167
Explanation
In order to sell LPG tax-unpaid to a purchaser who owns a licensed LPG-powered motor vehicle, the
LPG vendor must inspect the purchaser’s bulk storage tank to determine if it has a liquid transfer line.
LPG Vendor Information
LPG Vendor
License Number
Address
Customer Information
Customer Name
Customer Address
The customer listed above owns a licensed, LPG-powered vehicle.
Signature
I declare and affirm under the penalty of perjury that on ____________________, 20_________, I inspected
the liquefied petroleum gas bulk storage tank belonging to the customer identified above, and on that
date, the tank had no liquid transfer line that could be used to fill the supply tank of an LPG-powered
vehicle.
Title
Date
Signature
Retain this affidavit in your files for audit purposes.
Notarization
Subscribed and sworn before me this ______________ day
of __________________________, 20_________.
Affix Seal Here
_____________________________________________
Notary Public
My commission expires on _________________________
PRINT FOR MAILING
CLEAR FORM
1.

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