A motor fuel retailer may, within thirty days of the occurrence, demand payment from the motor vehicle owner for the motor fuel received by sending a notice by certified mail, return receipt requested. The notice shall be prescribed by the Department of Public Safety and include the following information: (1) The name, address, and license plate number of the motor vehicle owner; (2) Date the act occurred; (3) Type of motor fuel; (4) The unpaid dollar amount; (5) The service charge; (6) A citation of §§ 22-30A-40 and 22-30A-43 ; and (7) The employee's and employer's signature. Source: SL 2005, ch 121 , § 3.