Customer Fuel Self Certification Customer Fuel Self Certification Name First Last Billing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Delivery Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone Number(Required)Is the house number clearly marked & visible from the road?(Required) Yes No Fill Location?(Required)1 O'clock2 O'clock3 O'clock4 O'clock5 O'clock6 O'clock7 O'clock8 O'clock9 O'clock10 O'clock11 O'clock12 O'clockHow to find your fill location: Facing your house, think of it as a clock. The front of your house being 6 O'clock and the back of the house being 12 O'clock. Please choose which number represents where the fill location is.Is their clear access to the Fill Pipe for deliveries?(Required) Yes No What needs to be done to make the fill accessible?(Required) Is the tank and all piping in good condition? Yes No If No, What needs to be repaired?(Required) Are there any signs of moisture at any of the connections or tank?(Required) Yes No Is there any signs of rust on the tank?(Required) Yes No Has your system ever been put out of service?(Required) Yes No Please explain why your system was put out of service(Required)When was your system last serviced?(Required) Upload Picture of the front of the house from the street(Required)Max. file size: 50 MB.Upload Picture of outside fill location(Required)Max. file size: 50 MB.Upload Picture of the tank(Required)Max. file size: 50 MB.Upload Picture of indoor piping Drop files here or Select files Max. file size: 50 MB. Special Delivery Instructions:Customer Responsibility(Required) I certify my tank is in good condition and take responsibility for any failure of the tank or plumbing that may result from age or failure to keep up with maintenance. Green Acres Fuel will not be held responsible.