Acknowledgment of Propane Tank Ownership

This form should only be filled out if you OWN your propane tank and it is currently on your property.

Date

YYYY

Name

First Name

Last Name

Address

City

State

Zip

Directions:

Phone Number

Select Tank Size

100 gallon tank

250 gallon tank

325 gallon tank

500 gallon tank

1,000 gallon tank

Serial Number

Signature *

First Name

Middle Name

Last Name

BY SUBMITTING THIS FORM, I CERTIFY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. BLUE RIDGE ENERGIES, LLC IS AUTHORIZED TO MAKE ANY AND ALL INQUIRIES NECESSARY FOR ACTION ON THIS ACKNOWLEDGEMENT. I ALSO ACKNOWLEDGE THAT I OWN THE TANK WHICH BLUE RIDGE ENERGIES, HAS BEEN ASKED TO FILL AND RELEASE BLUE RIDGE ENERGY, LLC, FROM ANY AND ALL LIABILITIES ASSOCIATED WITH THEIR COMPANY FILLING MY PROPANE TANK (LISTED ABOVE).