Form Ptc-1 - Petroleum Tank Release Clean-Up Fund Return

PTC-1

Petroleum Tank Release Clean-Up Fund Return

Date

Authorized signature and title

Phone

1 Number of gallons of gasoline

For the month of November 2004.

subject to petroleum tank release

Must be filed by December 23, 2004.

clean-up fee (from Form PDA-46, line 5) . . . . . . 1

2 Number of gallons of fuel oil subject to

petroleum tank release clean-up fee

(from Form PDA-46, line 5) . . . . . . . . . . . . . . . 2

3 Total gallons on which petroleum tank

release clean-up fee is due . . . . . . . . . . . . . . 3

4 Multiply line 3 by $.02. This is the fee due.

All payments must be made electronically . . . 4

Mail to: Minnesota Revenue, Mail Station 3333, St. Paul, MN 55146-3333.

Phone: 651-297-4130. TTY: Call 711 for Minnesota Relay Service.

(9/04)

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Parent category: Financial