Form R-9016 - Registration Application For Oil Spill Contingency Fee

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R-9016 (6/05)
Registration Application for Oil Spill
Contingency Fee
Taxpayer Services Division
P.O. Box 201
Baton Rouge, LA 70821-0201
(225) 219-7656
(225) 219-2114 (TDD)
Revenue Account Number __________________________________________________________________________
Name
__________________________________________________________________________________________
Address
City
State
ZIP+4
Mailing address____________________________________________________________________________________
Address
City
State
ZIP+4
Location address __________________________________________________________________________________
Area code and telephone number ____________________________________________________________________
Contact person ____________________________________________________________________________________
Briefly describe below your operations as they relate to the handling of crude oil:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Average number of barrels unloaded monthly:
______________________ domestic
______________________ foreign
Average number of barrels loaded monthly:
______________________ delivered within Louisiana
______________________ exported
__________________________________________________________________
Signature of applicant
__________________________________________________________________
Date

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