Form Dr-166 - Florida Pollutant Tax Application - 2010
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2DR-166
Florida Pollutant Tax Application
R. 05/10
Mail this application with $30 fee to:
For DOR Use Only
Account Management/Fuel Unit
License Number
Florida Department of Revenue
5050 West Tennessee St. Bldg L
Tallahassee FL 32399-0100
Approval Date
Examiner’s Initials
1.
Business Name: __________________________________________________________________________________________________
2.
Owner’s Name: ___________________________________________________________________________________________________
(Individual, Corporation, Partnership, Limited Liability Company)
3.
Federal Employer Identification Number:
–
4.
Location Address: ________________________________________________________________________________________________
(Street Address)
__________________________________________________________________________________________________________________
(City, State, ZIP)
5.
Mailing Address: __________________________________________________________________________________________________
(if other than location address)
(Street Address)
__________________________________________________________________________________________________________________
(City, State, ZIP)
6.
Type and Legal Organization: (Please check only one)
A)
Corporation (check one):
C Corp
S Corp
If corporation, check any of the appropriate boxes that apply:
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Publicly Held Corporation
Privately Held Corporation
Wholly Owned Subsidiary of a Publicly Held Corporation
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B)
Partnership (check one):
General
Limited
Joint Venture
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C)
Limited Liability Company (check one):
Single Member
Multi-member
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D)
Individual/Sole Proprietorship
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E)
Business Trust
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F)
Governmental Agency
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7.
Corporate or Partnership Information (If you are an individual proprietor, do not complete this section):
Percent Business Interest
Name*
Home Address (include City, State, ZIP)
Social Security Number
or Corporate Title
*Full name of corporate officers, partners, directors, and stockholders with a controlling interest (attach separate sheets if necessary)
Note: Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration of Florida’s taxes.
SSNs obtained for tax administration purposes are confidential under sections 213.053 and 119.071, Florida Statutes, and not subject to disclosure
as public records. Collection of your SSN is authorized under state and federal law. Visit our Internet site at and select
“Privacy Notice” for more information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized
exceptions.
8.
Contact Person’s Name: ___________________________________ Phone: (______)____________Fax: (_______)_________________
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9.
Type of Application:
New Applicant/Business
Date Business Began or Will Begin: ________________________________
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Legal Entity Change
Date of Change: _________________________________________________
Previous Pollutants License Number: ___________________________________________________________
10. Nature of Business: This business will (check all that apply):
Produce
Import or cause to be imported (into Florida)
Export
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Be entitled to a refund on the following taxable pollutants:
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Petroleum Products
Ammonia
Pesticides
Chlorine
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Motor Oil or Other Lubricants
Crude Oil
Solvents
Perchloroethylene
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Other (specify)
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