Form Wv/mft-App - West Virginia Motor Fuel Excise Tax License Application Page 2
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4E. PRODUCT INFORMATION
Check the type(s) of product you will be handling.
□ 150 – #1 Fuel Oil
□ 124 – Gasohol
□ 284 – Biodiesel – Undyed
□ 225 – Liquefied Natural Gas
□ 125 – Aviation Gasoline
□ 065 – Gasoline
□ 072 – Kerosene – Dyed
□ 224 – Compressed Natural Gas
□ 130 – Aviation Jet Fuel
□ 228 – Diesel – Dyed
□ 142 – Kerosene – Undyed
□ Other – Produce Code ____________
□ 122 – Blending Components
□ 160 – Diesel – Undyed
□ 054 – Propane
Product Type
___________________
F. MOTOR FUEL PURCHASE/RECEIPT INFORMATION (Attach additional pages if necessary.)
Provide the following information on all suppliers from whom you will purchase motor fuel and on all exchange partners from whom you will receive motor fuel from
inside the terminal transfer system.
Supplier
Point of Origin
Point of Destination
Product
Name
Code
City
State
City
State
Exchange Partner
Point of Origin
Point of Destination
Product
Name
Code
City
State
City
State
G. TERMINAL OPERATOR INFORMATION
If you own, operate, or otherwise control a terminal, you must complete this section.
Will you maintain motor fuel storage and distribution facilities to which a terminal control number has been assigned by the IRS?
□ Yes
If yes, you must complete Section O – Storage Facility Information.
□ No
H. REFINERY INFORMATION (Attach additional pages if necessary.)
If you own, operate, or otherwise control facilities with petroleum-refining capabilities in West Virginia, you must complete this section.
1. Refinery Street Address
City
State
Zip Code
WV
2. Provide the product code and estimated number of gallons for each product you plan to refine monthly.
Product Code
Gallons
Product Code
Gallons
Product Code
Gallons
I. SUPPLIER INFORMATION
IMPORTANT: All suppliers must complete Section O – Storage Facility Information.
If you are applying for a supplier’s license or permissive supplier’s license, you must complete this section.
1. Will you be a position holder in a terminal?
□ Yes
□ No
2. Will you receive motor fuel through a two-party exchange
□ Yes
If yes, you must complete Section F – Motor Fuel Purchase/Receipt Information.
agreement(s)?
□ No
J. BLENDER INFORMATION (Attach additional pages if necessary.)
If you will blend petroleum products in West Virginia, you must complete this section.
What is the estimated number of gallons of taxable motor fuel you will blend in a fiscal year?
Blending Site Physical Address
City
State
Zip Code
Tank Capacity (gallons)
WV
Provide a complete description of your blending operation.
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