Form Mfd 1-S/af - Motor Fuel & Aviation Fuel Distributor Report - Department Of Safety - New Hampshire Page 5

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STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
ROAD TOLL BUREAU
MOTOR FUEL & AVIATION FUEL DISTRIBUTOR REPORT
SCHEDULE OF RECEIPTS
Schedule
Product
Company Name:
License Number:
FEIN:
Type
Type
Month
Year
-
(4)
(1)
(2)
(3)
(5)
(6)
(7)
(8)
(9)
(10)
Point of
Carrier Name
Carrier
Mode
Supplier
Supplier
Date
Document
Gross
Net
Origin
Destination
FEIN
FEIN
Received
Number
Gallons
Gallons
Page Total
FORMS MFD 2, 2E, 2F, 3, 4 (Revised 03/2010)

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