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Refill Request
Refill Request Form
All fields required
Name on Account:
Account Number:
Phone #:
Email:
Billing Street:
Billing City:
Billing State:
AL Alabama
AK Alaska
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FL Florida
GA Georgia
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Lousiana
ME Maine
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
OH Ohio
OK Oklahoma
OR Oregon
PA Pennsylvania
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
Same as Billing:
No
Yes
Tank Street:
Tank City:
Tank State:
Tank Zip:
Please select a location near you:
Burchinal
Hanlontown
Lawler
Nashua
New Hampton
Request Type:
Propane
Fuel Oil
Fuel
FOR PROPANE:
Tank Percentage:
Estimate of Gallons Requested:
Unknown – Please Fill Tank
Less than 200 Gallons
200 Gallons
250 Gallons
300 Gallons
More than 300 Gallons
Comments:
FOR FUEL OIL:
Inches in Tank:
Gallons Requested:
Unknown – Please Fill Tank
Less than 200 Gallons
200 Gallons
250 Gallons
300 Gallons
More than 300 Gallons
Comments:
FOR FUEL:
Inches in Tank:
Type of Fuel:
Gasoline
Off-Road Diesel
On-Road Diesel
Gallons Requested:
Unknown – Please Fill Tank
Less than 200 Gallons
200 Gallons
250 Gallons
300 Gallons
More than 300 Gallons
Comments: