Form Wvmft-507 -West Virginia Motor Fuel Transporter

WEST VIRGINIA MOTOR FUEL TRANSPORTER

PO BOX 2991

WV/MFT-507

REV 12/6

CHARLESTON, WV 25330-2991

(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627

C

WV CODE § 11-14C-40 IMPOSES A $50 PENALTY FOR THE LATE FILING OF THIS REPORT

Check applicable boxes

□ Address has changed since prior report

□ Amended report

REPORT MUST BE FILED MONTHLY EVEN IF NO ACTIVITY OCCURRED DURING THE MONTH

□ Final Report for closed business

You must keep a copy of this report for your records

Period Ending (Month, Day and Year)

FEIN

NAME

Mailing Address

City

State

Zip Code

Due Date (Month, Day and Year)

Telephone Number

Fax Number

E-Mail Address

(

)

(

)

PRODUCT LOAD INFORMATION

DESCRIPTION

GROSS GALLONS

NET GALLONS

1. Product loaded in West Virginia at a Terminal or Bulk Plant and delivered to another state (Schedule 1).

2. Product loaded in another state at a Terminal or Bulk Plant and delivered into West Virginia (Schedule 2

).

3. Product loaded in West Virginia and delivered into West Virginia

Schedule 3).

(

4. TOTAL GALLONS OF MOTOR FUEL TRANSPORTED.

(Add Lines 1, 2, and 3).

CERTIFICATION

I certify that I have read this report and all supporting documents and know their contents and that all information on both the report and supporting documents are true, accurate, and complete.

Authorized Representative’s Name (Please Print)

Title

Authorized Representative’s Signature

Date

*O11110401W*