Form Boe-400-Fta - Application For Fuel Tax/fee Account Number, License Or Permit Page 3
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3BOE-400-FTA (S2) (8-01)
APPLICATION FOR FUEL TAX/FEE ACCOUNT NUMBER, LICENSE OR PERMIT
VESSEL/PIPELINE OPERATOR INFORMATION REQUIRED (PC program)
No (if yes, please provide the following information)
Do you operate a vessel that delivers petroleum products to any location in California?
Yes
Vessel name
Vessel ID
Delivery point
Do you operate a pipeline in California that delivers petroleum products?
Yes
No (if yes, please provide the following information)
Pipeline name
Pipeline location (include starting and ending location)
INDUSTRIAL USERS INFORMATION REQUIRED (PM program)
1. Are you receiving gasoline blendstocks by bulk transfer for your own use in the manufacture of any product other than finished
gasoline?
Yes
No
2. Do you use any gasoline blendstocks in highway vehicles?
Yes
No
3. Do you sell gasoline blendstocks?
Yes
No
4. How are the gasoline blendstocks received? (please describe)
5. Name, address and BOE license number of your supplier(s)
6. What is the estimated number of gallons received per month?
7. What product(s) is being produced?
8. Date you started using gasoline blendstocks
EXEMPT BUS OPERATOR DIESEL INFORMATION REQUIRED (DB program)
Please describe your business operation
Note: An exempt bus operation shall not be applicable to a charter party carrier of passengers.
SECTION V: CERTIFICATION
I certify and declare, under penalty of perjury, that the information contained herein is correct to the best of my knowledge
and that I am authorized to sign and certify this application.
NAME (typed or printed)
TITLE
SIGNATURE
DATE
Return Application to: Board of Equalization
Fuel Industry Section
450 N Street, P.O. Box 942879 MIC:30
Sacramento, CA 94279-0030
916-322-9669
PUBLICATIONS
FOR BOARD USE ONLY
FURNISHED TO APPLICANT
REPORTING BASIS
Pub. 88
RETURNS/FORMS
Pub. 12
RECEIVED BY:
Pub.
6
SECURITY
Pub.
3
APPROVED BY
Pub. 19
Pub. 14
REMOTE INPUT DATE
BY
Pub. 70
Pub. 84
DATE
EFT
PERMIT/LICENSE ISSUED
CLEAR
PRINT
Fuel Taxes/Fees Application
August 2001
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