Participant Name ___________________________________ Part



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|Prospect Site Name |

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|Street Address |

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|City State Zip |

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|County Province __________ Population _ |

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|HWY ______ State Route _____ Exit # _______Site phone #________________ |

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|Nearest Rack City Miles to Site |

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|Brand of fuel sold: Gas Diesel |

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|Major Oil ID/Brand Site# |

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|Fuelman Accepted? Y / N If yes, Fuelman site number: |

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|Site Controller Type Model |

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|Dispenser Manuf. Model MPD Yes / No |

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|VSAT Landline Internet |

PRODUCTS AVAILABLE AT SITE

| |

|Participant Name: ___________________________________ |

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|Part# _______ Date _______________ |

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|Requester’s Name __________________ |

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|E-Mail __________________________ |

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|Office Phone_____________________ |

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|Office Fax _______________________ |

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|Est. Go Live Date _________________ |

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|A CHECK FOR THE SITE REGISTRATION FEE MUST ACCOMPANY |

|THIS SITE REGISTRATION. NON-REFUNDABLE IF APPROVED. |

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|FOR CFN USE ONLY |

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|PART# SITE# REGION |

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|CL: NET: |

|TYPE: G / P / N |

|MF: |

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|STATE: COUNTY: CITY: |

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|RACK: GH: DH: |

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|LONGITUDE: |

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|LATTITUDE: |

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|RCVD: |

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|APPRVD: |

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|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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