Form 74-100-99-1 - Petroleum Tax Registration Application - 1999 Page 2
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1
2Mississippi
Petroleum Tax Registration Application
13. Where will records be maintained?
Kind of product or service?
14.
Persons applying for Natural Gas - Compressed Gas Users Permits must provide the information requested below.
15.
Are you producing or purchasing natural gas or crude oil severed from the land or water within Mississippi? Yes
No
Persons applying for Petroleum Distributors Permits must provide the information requested below.
16.
Will gasoline be sold or distributed in Harrison County, Hancock County or Jackson
Yes
No
Will you use your own transport truck to import gasoline or diesel fuel into
Yes
No
Will you have gasoline or diesel fuel in storage at a marine or pipeline terminal in this
Yes
No
If yes, please provide the terminal name and location.
Estimate the average volume (in gallons) handled per month.
Gasoline........................................
Aviation
Diesel
Jet
Compressed
Other................................................
Kerosene......................................
Lubricating (Motor)
17. Refund Gasoline Users
Yes
No
Do you have storage tanks for Refund Gasoline?
Yes
No
Are the tanks marked as required by law?
Storage capacity (in gallons) of each tank
Location of tank(s)
List all equipment that will use refund gasoline.
Make
Model
Identification Number
I hereby certify that the above statements are true and correct to the best of my knowledge and belief. As indicated on this
completed form, I hereby apply for the appropriate permit(s) to engage in business. I agree to pay any and all taxes due the State
of Mississippi and to comply fully in all respects with the applicable Mississippi Tax Laws and any corresponding rules and
regulations.
Print or type name of person signing application
Title
Date
Applicant's Signature
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