A statement upon a form approved by, and a copy of which shall be filed with, the director of labor and training, signed by the seller or the seller’s agent stating the seller’s name and business address; the name and address of the purchaser; the date of delivery; and the kind, size, and weight of the coal or coke, shall accompany the delivery of any coal or coke sold to consumers in the state in quantities in excess of one hundred pounds (100 lbs.) and shall be given to the purchaser or purchaser’s agent upon delivery of the coal or coke.