Business Registration

Business Information

Business Name	Richmond Petroleum Inc
Business Street Address (Including Unit or Suite, if applicable)	---
Business Phone	+18156782929
Email Address	---
Would you like to sign up for the Village E-Blast for current events and information?	---

Business Owner Information

Business Owner(s) Name	---
Business Owner(s) Home Address	---
Business Owner(s) Phone Number (Home or Cellphone)	---

Is This A New Business?

Is This A New Business?

No, my business was registered under the same name prior to May 1st of this year.

Other Important Information

Illinois Sales and Use Tax and/or Retailers Occupation Tax	---
Operating Days	Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday
Operating Hours	17 hours per day
Number of Shifts	2
Number of Employees	3
Nature of Business	Gas Station with Convenience Store

Fueling Stations

Does your business have fueling stations on site?

Yes

Hoses

Number of gas hoses

12

Police Required Information

Burglar Alarm	Yes
Fire Alarm	Yes
Hazardous Materials	Yes

Burglar Alarm

Please Provide Additional Information	---
Monitoring Agency	---
Monitoring Agency Telephone Number	---
Alarm Type	---

Fire Alarm Information

Please Describe Alarm Box Location	---
Monitoring Agency	---
Monitoring Agency Telephone Number	---
Alarm Type	---

Hazardous Materials

Provide Detail Information

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Emergency Contacts: Please provide 3 names/phone numbers of key holders who are available 24 hours in case of an emergency.

1) Name	Piyush Patel
1) Phone Number	+18153478343
1) Alternate Phone Number
2) Name	Udayan Trivedi
2) Phone Number	+18152459196
3) Name	Piyush Patel

Late Fees

Was this submitted after May 22?

No

Prorated Fees

Was this submitted between August 1 - October 31?	No
Was this submitted between November 1 - January 31?	No
Was this submitted After February 1?	No

Certification Number

Certificate No

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