Declaration of Inspection

Fuel Transfer — Non-Ethanol Rec 90 Gasoline

Operator Only — Unattended Delivery

Complete all fields and sign as operator. This form will be emailed to [email protected].

Job Details

Date*

Truck ID

Time Start*

Time End

Location / Dock*

Vessel*

Customer*

Fuel Type

Gallons Pumped*

Pre-Transfer Checklist

Hose inspected for wear or damage

Emergency shutoff accessible and tested

Fire extinguisher present and charged

Spill kit on hand

No smoking / no open flames in area

Engines secured (off)

Vessel secured to dock

Communications established with vessel rep

Weather acceptable for transfer

Vent monitored during fill

Fill connection verified and seated

Post-Transfer Checklist

No spills or leaks observed

Area clean and clear

Hose drained and disconnected

Comments

Operator Signature

Operator

Name*

Signature*

Date*

Submitting emails a complete copy to [email protected] with all job details, checklist results, and signatures attached.

Dockside Fuel Solutions LLC · Crystal River, FL · (352) 322-7012 · [email protected]