Form Wv/mft-503 - West Virginia Terminal Operator Report
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2WV/MFT-503
*O10110401W*
REV 12/06
WEST VIRGINIA TERMINAL OPERATOR REPORT
O
PO BOX 2991
CHARLESTON, WV 25330-2991
(304) 558-8623; (304) 558-8624; (304) 558-8625; (304) 558-8626; (304) 558-8627
You must keep a copy of this report for your records
Check applicable boxes
□ Address has changed since prior report
WV CODE § 11-14C-40 IMPOSES A $50 PENALTY FOR THE LATE FILING OF THIS REPORT
□ Amended report
PLEASE PRINT OR TYPE
□ Final Report for closed business
TERMINAL INFORMATION - A Separate Report And Schedules Must Be Filed For Each IRS Approved Terminal
Period Ending (Month, Day and Year)
TERMINAL NAME
IRS Terminal Control Number (TCN)
Due Date (Month, Day and Year)
Terminal Address
City
State
Zip Code
TERMINAL OPERATOR INFORMATION
FEIN
Operator Name
Mailing Address
City
State
Zip Code
Telephone Number
Fax Number
E-mail Address
(
)
(
)
INVENTORY INFORMATION
USE NET GALLONS
Gasoline/
Dyed Diesel and
Blending
Undyed
Aviation
Aviation
Inventory, Receipts, and
Undyed Diesel
Other
Gasohol
Dyed Kerosene
Components
Kerosene
Gasoline
Jet Fuel
Disbursements Summary
1. BEGINNING INVENTORY
2. TOTAL RECEIPTS
Enter Grand Total from Schedule 2A
3. TOTAL GALLONS AVAILABLE
Line 1 plus Line 2
4. TOTAL DISBURSEMENTS
Enter Grand Total from Schedule 4A.
5. TOTAL ACCOUNTABLE GALLONS
Line 3 minus Line 4
6. GAIN/LOSS. Enter + or – signs.
7. ACTUAL ENDING INVENTORY
Line 5 plus or minus Line 6.
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
Telephone Number
Fax Number
E-mail Address
(
)
(
)
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