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Class 5 - Recreational Vehicle or Mobile

  1. List all dispenser tanks, size and location

  2. Include mechanical license #

  3. Read and initial the following.

  4. 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 if the State Fire Marshal or K.S.A. 55-1812 shall be cause for suspension or revocation of the license held.

  5. Leave This Blank:

  6. This field is not part of the form submission.