Participant Name ___________________________________ Part
| |
|Prospect Site Name |
| |
|Street Address |
| |
|City State Zip |
| |
|County Province __________ Population _ |
| |
|HWY ______ State Route _____ Exit # _______Site phone #________________ |
| |
|Nearest Rack City Miles to Site |
| |
|Brand of fuel sold: Gas Diesel |
| |
|Major Oil ID/Brand Site# |
| |
|Fuelman Accepted? Y / N If yes, Fuelman site number: |
| |
|Site Controller Type Model |
| |
|Dispenser Manuf. Model MPD Yes / No |
| |
|VSAT Landline Internet |
PRODUCTS AVAILABLE AT SITE
| |
|Participant Name: ___________________________________ |
| |
|Part# _______ Date _______________ |
| |
|Requester’s Name __________________ |
| |
|E-Mail __________________________ |
| |
|Office Phone_____________________ |
| |
|Office Fax _______________________ |
| |
|Est. Go Live Date _________________ |
| |
|A CHECK FOR THE SITE REGISTRATION FEE MUST ACCOMPANY |
|THIS SITE REGISTRATION. NON-REFUNDABLE IF APPROVED. |
| |
|FOR CFN USE ONLY |
| |
|PART# SITE# REGION |
| |
|CL: NET: |
|TYPE: G / P / N |
|MF: |
| |
|STATE: COUNTY: CITY: |
| |
|RACK: GH: DH: |
| |
|LONGITUDE: |
| |
|LATTITUDE: |
| |
|RCVD: |
| |
|APPRVD: |
| |
|OTHER: |
FUELS Available CFN
by CFN card Product Code
USLD #2 □ (53)
USLD #2 Dyed □ (38)
USLD #1 □ (39)
ULSD #1 Dyed □ (40)
ULSD Premium #2 □ (80)
ULSD Premium #2 Dyed □ (81)
CARB ULSD #2 □ (03)
CARB ULSD Dyed □ (23)
BIO Diesel ( B-____ %) □ (54)
Regular Unleaded □ (04)
Mid-grade Unleaded □ (05)
Premium Unleaded □ (06)
Ethanol Blend ( ____ %) □ (29)
Gasoline Oxygenation Program Yes NO
Other Fuel_____________ □ ( __ )
Other Fuel_____________ □ ( __ )
OTHER PRODUCTS / SERVICES Available on cash basis THER SITE INFORMATION
Motor Oil Qts. □ □ Within ¼ mile from freeway/highway Y / N
Motor Oil Gal. □ □ Height restriction below 13’6” Y / N
Motor Oil Bulk □ □ Security Cameras Y / N
Propane □ □ 18 Wheels access Y / N
Kerosene □ □ If NO, is Truck Limited to Bobtails______; or Cars Only_____?
Solvent □ □ Is the site available by card on a 24-hour basis? Y / N
Racing Gas □ □ Is there any other business currently operating at this site?
Truck / Auto Parts □ Explain:
Truck Parking □ Do you own_____ operate_____ supply product_____ to the site?
Convenience Store □ If you lease the property, when does the term expire?
Motel □ If you supply product how long is it under contract?
Showers □ Est. Fleet/Commercial gallons per month:
Truck / Car Wash □ □ Diesel gal._________________; Gasoline gal.________________
Scales □ □ Retail_____ Retail/Cardlock_____ Cardlock_____Truckstop _____
Pay Phone □
Air □ OPIS GASOLINE SETTLEMENT BASIS: Please mark one.
Truck Stop □ Branded Rack Average ___
Water □ Unbranded Rack Average (requires 3 or more suppliers) ___
Restaurant □ Rack Average (branded & unbranded average) ___
Rest Rooms □ □
Sanitary Dump □ Premier Site Status Y / N
Other If Yes, please submit Premier Site Status Request Form
................
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