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Class 4 - Cylinder Filling
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Full Company Name (Include DBA)
List all dispenser tanks, size and location
1. Name of Business (if different)
2. Name of Business (if different)
3. Name of Business (if different)
4. Name of Business (if different)
Name of supplier from whom you buy LP Gas
Name and location of plants where you load
Read and initial the following.
We have read the Kansas statutes and rules that regulate this license and will abide by them.
We understand that all employees dispensing LP Gas are required to hold CETP or KSFM certification.
We understand that this license is non-transferable and any change in name or ownership will be reported to the Office of the State Fire Marshal.
We agree that all personnel are required to attend a mandatory safety school annually and all personnel have attended or will attend a safety school sanctioned by the Office of the State Fire Marshal, the Kansas Department of Transportation, or the Kansas Highway Patrol.
By typing my name and date below, I certify that this information is true and correct. Any false or fraudulent statement or failure to comply with the rules and regulations promulgated by the Office of the State Fire Marshal or K.S.A. 55-1812 shall be cause for suspension or revocation of the license held.
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