Gas Decal Purchases Form 504

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WESTKEY GRAPHICS 604-421-7778 or TOLL FREE 1-800-663-9952
06501
Kamloops 250-314-6000 Langley 604-539-3573 Prince George 250-614-9972 Fax: 250-377-4406 Fax: 604-539-3570 Fax: 250-614-9949
Please refer to our web site, or contact one of the Regional Offices below to locate a BC Safety Authority office nearest you: Coquitlam Kelowna Nanaimo Victoria 604-927-2041 250-861-7313 250-716-5200 250-952-4444 Fax: Fax: Fax: Fax: 604-927-2047 250-861-7349 250-716-5212 250-952-4458
Toll Free Number: 1-866-566-7233 (SAFE) www.safetyauthority.ca
New Westminster 505- 6th Street, Suite 200, New Westminster, BC V3L 0E1 Local: 778-396-2000 Fax: 778-396-2174 Toll Free: 1-866-566-7233 (SAFE) Fax: 1-888-660-3508 Website: www.safetyauthority.ca
GAS PURCHASES/MISCELLANEOUS Note: The information on this form is collected to administer the provisions of the Safety Standards Act. If you have any questions about the collection, use or disclosure of this information, contact the Records, Information & Privacy Analyst for the BC Safety Authority at our toll free number (see top of form). Fees payable to BC Safety Authority. A.
Name: Enter your appropriate Operating permit, Contractor or Product Approval number: Suite no.: City: Street no.: Province: Street name: Postal Code: Street type: Phone : ( )
YYYY MM DD
Application (please print clearly - provide business contact information)
Print name:
Signature:
Date:
B.
Purchase of decals
Temporary heater decal (operating permit number required) Appliance/Installation (contractor number required) Replacement gas fitter/gas contractor licence, miscellaneous
All items below are GST applicable: Natural gas vehicle decal (operating permit number required) Propane gas vehicle decal (operating permit number required) Recreational vehicle decal (operating permit number required) Appliance decals (BC approval - product approval number required)
Volume of decals required:
X
$
YYYY MM
(per decal)
DD
Fee:
$
Decal list (ie. Log of previously used decals) returned on:
C.
Office use only
to to Fee: Fee: Fee: $ $ $
Decal number from: Decal number from: Gas distribution lines Gas miscellaneous
GST: $ 87391 2802 RT 0001 Total Fee: $
YYYY MM DD
Office:
File number:
Payment date:
Payment method:
Initials: Return completed form and fee to the BC Safety Authority office in your area with any documentation required. Please do not detach copies until authorized. White - Office Yellow - Audit Green - Applicant
FRM-0504 (2009/05/05)