Transporter Report Form - State Of South Dakota

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Transporter Report
Company Name
License Number
Reporting Period
Instructions: Circle the appropriate schedule type you are reporting on this form and record the appropriate product type in the space provided for each
disbursement listed below.
Transporter Schedule Types
Product Types
65 – Gasoline
124 – Gasohol
1b – All deliveries of fuel from in-state locations to outside South Dakota (exports)
228 – Dyed Diesel Fuel
123 – Alcohol
160 – Undyed Diesel Fuel
130 – Jet Fuel
2b – All deliveries of fuel from out-of-state locations to inside South Dakota (imports)
125 – Aviation Gasoline (AVGAS)
142 – Kerosene
999 – Other (please list:______________)
244 – Methanol
Person Hiring the carrier
Seller
Delivered To:
10
11
12
1
2
3
7
8
9
Delivery
Document
Gross
Product
Company
Company
4
5
6
Date
Number
Gallons
Type
Name
FEIN
Name
FEIN
Name
Address
FEIN
Mode
Origin

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