Phone #
Address
First Name
Applicant Details
Registration Type
ZIP
State
City
{[ADDR]}
{[CITY]}, {[STATE]} {[ZIP]}
{[APHONE]}
{[AWEBSITE]}
Email
{[PNAME]}
Last Name
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  • Contacts
  • Details
  • Attachments
  • Certification
Last Name
Name
Address
Do you own the premise to be licensed?
Email
City
If Other
Address
Ownership Type
Mailing City, State, ZIP
Email
Total % Owned
Who is operator?
Phone #
ZIP
Emergency Contact Details
Building Owner Details
State
Last Name
First Name
Phone #
Last Name
Operator Details
First Name
Additional Owner Details
Phone #
State
Owner Details
First Name
City
Address
Email
ZIP
Phone #
Station phone #
Total # of Dispensers
State
Business Details
City
Trade Name
Registered Trade Name
Federal ID #
# of Gasoline tanks
Address
# of diesel / oil tanks
ZIP
# of total tanks
Gasoline Brand
Attach any applicable documentation
Attachments
Type Full Name :
Sign With Hand
I, the undersigned, respectfully make an application for the renewal / transfer of a license to maintain and operate a gasoline station on premises. If granted this permit, I shall adhere strictly to the provisions of the Municipal Code Chapter 298, pertaining to the storgae and sale of gasoline, diesel fuel and oil.
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Amount Due
Fee Schedule
Certification
Applicant Signature