e- SV

FORM

DOC NO. DATE (DD/MM/Y Y Y Y ) FILLING PLANT NA ME PLANT CODE

09/11/2021 US AR LPG P LANT 12531
CONS UMER NO. DEALER CODE DEALER'S NA ME AND ADDRESS
11122200 VARADVINAYAK GAS AG ENCY
SPORTSLIFE CO-OP HO US ING SOCIETY -SHOP NO -
9, P LOT NO - 9, SECTOR - 1- KALAMBOLI
KALAMBO LI
Maharas htra
Pin:410218
CONNECTION REGISTRATION EQUIP MENT CODE NOS. A MOUNT
TYPE NA TURE NO. 3210839000001505 CYLINDER 036 2 2900
6 1 DATE 04/11/2021 REGULATOR 1 150
A MOUNT IN WORDS Three Thousand and Fifty TOTAL 3050
CONS UMER NA ME zamar irtaja khan
CONS UMER ADDRESS Taloja Phase 2 Sector 27 Asawari Society E10 Flat no 404 ,Navi Mumbai
Maharas htra
Pin:410208

OLD PARTICULARS DO C UMENT NO. DATE

DEALER CODE ORIGINA L SV
FILLING PLANT CODE CURRENT SV
CONS UMER NO. ADDL. SV
OIL COMPANY TV/CTA/SVCD

To be filled Manually in case of within the City Transfer

TRANSFER FROM TRANSFER TO

CTA NO/ DEALERS DEALERS
AUTH CODE CODE NA ME SIGN CONS UMER CODE NA ME SIGN EFF
NO. DT

REMARKS

09/11/2021 ____________________ TO BE SIGNED IN PRESENCE OF EACH OTHER 09/11/2021 ____________________

DATE DEALER'S SIGNATURE AS PER ITEM15 INREVERSE DATE CONSUMER'S SIGNATURE

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