Form Dr-166 - Florida Pollutant Tax Application

11. Storage Information: List the type of pollutant, location of storage facility, and estimated volume of taxable

DR-166

units imported, produced, or sold in Florida.

R. 05/10

Type of Pollutant

Location of Storage Facility

Taxable Units

12. Supplier Information: List all suppliers of pollutants.

Name of Supplier

License Number

13. Carrier Information: List the model, total tank capacity, year, and vehicle identification number (VIN) of all trucks, barges,

boats, or other equipment used to transport pollutants on the highways or waterways of Florida. Cab cards will be issued

for each motor vehicle or equipment used for transporting taxable pollutants.

Model

Total Tank Capacity

Year

VIN

14. Florida Secretary of State Certificate: If a corporation, list the state of incorporation: ____________________________________

List the name, address, and telephone number of the individual designated to accept service in Florida: _____________________

__________________________________________________________________________________________________________________

Attach a certified copy of the certificate authorizing such corporation to transact business in Florida, issued by the Florida Secretary of State.

15. Bonding Requirements

A surety bond in the amount of $______________________is enclosed. An assigned time deposit or an irrevocable letter of credit

may be accepted in lieu of a bond. If already operating as a producer or importer of pollutants, your bond amount will be three

times the average monthly pollutants tax paid or due during the preceding 12 calendar months. If a new registrant, your bond

amount will be three times your estimated projected monthly tax liability. The projection will depend on the quantity and tax rate

of the pollutant you produce or import during an average month. See detailed instructions for example.

Your bond will not exceed $100,000.

Affidavit of Applicant(s)

I, the undersigned individual(s), or if a corporation for itself, its officers, and directors, hereby swear or affirm under penalty of

perjury as provided in section 837.06, Florida Statutes, that I am duly authorized to make the foregoing application and that the

application and attachments are true and correct representation(s) of the premises to be licensed. If licensed, I agree that the place

of business may be inspected and searched, during business hours or at any time business is being conducted on the premises,

by officials and agents of the Department of Revenue for the purposes of determining compliance with Chapter 206, F.S.

Sworn to (or affirmed) and subscribed before me

this ____________ day of __________________ , _____________ .

State of _____________ County of ________________________________

_____________________________________________________________

_________________________________________________________

Signature of Notary Public

Signature of Applicant

__________________________________________

Print, Type or Stamp Name of Notary

Personally Known __________

or Produced Identification __________

Type of Identification Produced ___________________________________

Form Dr-166 - Florida Pollutant Tax Application - 2010 Page 2

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