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Name
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First
Last
Email
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Email
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Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Phone (Please leave a number that you will answer.)
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Customer Type
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New
Returning
Tank Location
*
Tank Location: Facing your house from the street, where is your fill located? Use the diagram above as a reference.*
Tank Size?
*
Tank Type?
*
Above ground
Underground
Basement
How many gallons?*
*
Method of Payment
*
Credit/Debit
Cash
Check
Are you out of oil?
*
Yes
No
Special Instructions
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Special Instructions (Slow fill, Check location, Call ahead, Senior Citizen or Military, etc.) Please do not give card information.*
Consent
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I agree to the privacy policy.
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Phone
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