Form Mft-6 R - Application For Renewal Of A Storage Facility Operator'S License - 2000 Page 2
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2Item number 11 must be completed by out-of-state businesses.
10. Give name, title and telephone number of person charged with the duty of filing motor fuel tax reports and location where reports are prepared and
records kept _____________________________________________________________________________________________________________
11. Give name, title and address of agent in New Jersey or registered New Jersey agent on whom service may be made (must be documented by letter
from agent)._____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
12. State kind of products handled: _____________________________________________________________________________________________
_______________________________________________________________________________________________________________________
13. New Jersey Storage Facilities
(a) List each tank, capacity, and location owned.
Capacity
Location
Type
in Gallons
Tank 1 _________________________________________________________________________________________________________________
Tank 2 _________________________________________________________________________________________________________________
Tank 3 _________________________________________________________________________________________________________________
Tank 4 _________________________________________________________________________________________________________________
Tank 5 _________________________________________________________________________________________________________________
Total Gallons _______________________________
NOTE: Commingled fuels with another person using the same storage tank is not acceptable for storage requirements delivered on a commission
basis and fuels delivered to a company-operated service station are taxable disposals at time deliveries are made and are not to be included
in your inventory.
14. List lease, sublease, terminalling agreement or throughput with any storage facility operator as defined in the Motor Fuels Act.
Capacity
Location
Type
in Gallons
Tank 1 _________________________________________________________________________________________________________________
Tank 2 _________________________________________________________________________________________________________________
Tank 3 _________________________________________________________________________________________________________________
Tank 4 _________________________________________________________________________________________________________________
Tank 5 _________________________________________________________________________________________________________________
Total Gallons _______________________________
15. Has applicant ever had a motor fuel license denied, suspended, cancelled or revoked in New Jersey or any other jurisdiction?
If yes, explain ___________________________________________________________________________________________________________
16. The undersigned application states (under penalty of perjury) that all the information contained in this application is true and accurate in every
particular.
____________________________________________________
_________________________________________________________
Name of Applicant
Signature of Owner, Partner or Officer
_________________________________________________________
Title
Date
All information must be provided before the application can be processed.
The information submitted will assist this office in the processing of your request.
The Division of Taxation reserves the right to conduct a thorough investigation prior to renewing this license.
Return completed application and $150 fee to: MOTOR FUEL TAX, PO Box 189, Trenton, NJ 08695-0189
FOR DIVISION USE ONLY
License No. ______________________________________________
Investigation Initiated ____________________________________________
Effective Date_____________________________________________
Investigation Completed __________________________________________
Approved ________________________________________________
Recommendations: ___________________________________________________________________________________________________________
MFT-6R
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