Form Boe-400-Fta - Application For Fuel Tax/fee Account Number, License Or Permit Page 2
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3BOE-400-FTA (S1B) (8-01)
APPLICATION FOR FUEL TAX/FEE ACCOUNT NUMBER, LICENSE OR PERMIT
Secretary
Co-Partner
Co-Manager
Member
Co-Owner
Trustee
21. FULL NAME (first, middle, last)
22. RESIDENCE ADDRESS (street, city, state, zip code)
23. SOCIAL SECURITY NUMBER (attach verification) (corporate officers excluded)
24. DRIVER LICENSE NUMBER (attach verification)
25. RESIDENCE TELEPHONE NUMBER
26. DAYTIME TELEPHONE NUMBER
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)
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)
27. SIGNATURE
SECTION III: BUSINESS INFORMATION
1. CURRENTLY DOING BUSINESS AS [DBA] ( write none if not applicable) Partnerships complete if business name different than name of partnership.
2. BUSINESS ADDRESS (do not list P.O. Box or mailing service) If two or more locations, please attach a list. TELEPHONE NUMBER
FAX NUMBER
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)
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)
3. MAILING ADDRESS (if different from above) (street, city, state, zip)
4. ADDRESS WHERE BOOKS AND RECORDS ARE MAINTAINED (street, city, state, zip)
TELEPHONE NUMBER
FAX NUMBER
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)
(
)
5. NAME OF PERSON TO CONTACT REGARDING ALL LICENSING ACTIVITIES
TELEPHONE NUMBER
FAX NUMBER
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)
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)
6. NAME OF PERSON TO CONTACT REGARDING TAX REPORTING ACTIVITIES
TELEPHONE NUMBER
FAX NUMBER
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)
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)
7. NAME OF BANK OR FINANCIAL INSTITUTION HOLDING THE PRIMARY BUSINESS ACCOUNT
ACCOUNT NUMBER
ADDRESS (mailing address, city, state, zip)
TELEPHONE NUMBER
FAX NUMBER
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)
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)
SECTION IV: REQUIREMENTS BY CATEGORY
(complete only the category that pertains to the respective account, license or permit for which you are applying)
UNDERGROUND STORAGE TANK INFORMATION REQUIRED (TK program)
Check the applicable box that best describes your business:
Other (please describe)
Gas Station
No (if yes, be sure to list all locations in Section III, line 2)
Does your business operate from more than one location?
Yes
Name of owner of real property for each site that has an underground storage tank
AIRCRAFT JET FUEL DEALER INFORMATION REQUIRED (MJ program)
What do you estimate as your average monthly taxable sales and use of aircraft jet fuel?
Name and BOE license number of each of your supplier(s)
OIL SPILL RESPONSE, PREVENTION AND ADMINISTRATION FEE INFORMATION REQUIRED (OA and OR program)
Check the applicable box that best describes your business:
Oil Refinery
Marine Terminal Operator
Pipeline Operator (in marine waters)
Other (please describe)
Does your business operate from more than one location?
Yes
No (if yes, be sure to list all locations in Section III, line 2)
USE FUEL VENDOR INFORMATION REQUIRED (AV program)
Check the applicable box that best describes your business:
Gas Station
Other (please describe)
What types of “use fuel” do you sell:
Liquefied petroleum gas (LPG)
Liquid natural gas (LNG)
Compressed natural gas (CNG)
Alcohol fuel
Other (please describe)
Does your business operate from more than one location?
Yes
No (if yes, be sure to list all locations in Section III, line 2)
USER USE FUEL INFORMATION REQUIRED (AU program)
Do you have bulk storage in California?
Yes
No
How many vehicles do you have that are powered by use fuel (liquefied petroleum gas, LPG; liquid natural gas, LNG; compressed natural gas, CNG; etc.)?
Fuel Taxes/Fees Application
August 2001
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Parent category: Financial