Form A-3609-MF "Motor Fuel Field Inspection Report" - New Jersey

What Is Form A-3609-MF?

This is a legal form that was released by the New Jersey Department of the Treasury - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 1996;
  • The latest edition provided by the New Jersey Department of the Treasury;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form A-3609-MF by clicking the link below or browse more documents and templates provided by the New Jersey Department of the Treasury.

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Download Form A-3609-MF "Motor Fuel Field Inspection Report" - New Jersey

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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
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
INSTRUCTIONS TO TAXPAYERS
Fuel dispensing equipment must be equipped with sealed gallon totalizers of at least six digits.
When dispensing equipment is newly installed or gallon totalizers are repaired or replaced, the
New Jersey Motor Fuels Section must be notified within seven days.
Telephone: (609) 984-7171.
Unauthorized removal of seals, placed on dispensing equipment found to be in violation of the
law, is a Crime of the Fourth Degree.
Any person who purposely obstructs, impairs, prevents, or attempts to prevent, a Division of
Taxation official from lawfully performing his official duties by means of intimidation, force,
violence, or physical interference, is guilty of a Crime of the Fourth Degree.
Crimes of the Fourth Degree are punishable by imprisonment not to exceed 18 months and/or fine
not to exceed $7,500.
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