Form Rt51 - Oil Discharge & Pollution Control Report
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1
2STATE OF NEW HAMPSHIRE
FOR OFFICE USE ONLY
Department of Safety
OFFICE AUDIT
Road Toll Bureau
BY:____________ DATE:________________
33 Hazen Drive, Concord, NH 03305
VERIFICATION
(603) 271-2311
BY:____________ DATE:________________
OIL DISCHARGE & POLLUTION CONTROL REPORT
___________________________________
NAME:
MONTH OF:__________________ YEAR:____________
Report must be postmarked no later than the 20th day of the month following the reporting
ADDRESS: ___________________________________
period.
CITY/TOWN: ___________________________________
TELEPHONE NO:_______________________________
STATE:
_________
ZIP: ______________
LICENSE NO.:____________________________
DIESEL
AUTO/AVIATION
JET FUEL
HEATING OIL
MOTOR OIL
OTHER
RECEIPTS
GASOLINE
FUEL
GALLONS
GALLONS
GALLONS
GALLONS
GALLONS
GALLONS
1. RECEIPTS FROM LOCATIONS OUTSIDE NH
2. RECEIPTS FROM LOCATIONS WITHIN NH
3. TOTAL CHARGES (LINE 1 AND 2)
4. SALES AND TRANSFERS OUT-OF-STATE
5. TAX PAID PURCHASES
6. TOTAL NON-TAXABLE (LINE 4 AND 5)
7. TOTAL TAXABLE (LINE 3 MINUS LINE 6)
TAX COMPUTATION
8. OIL POLLUTION ADJUSTMENTS
9. OIL POLLUTION TAXABLE GALLONS
10. OIL POLLUTION NET GALLONS
11. OIL POLLUTION FEE (LINE 10 *$.00125)
12. OIL DISCHARGE ADJUSTMENTS
13. OIL DISCHARGE TAXABLE GALLONS
14. OIL DISCHARGE NET GALLONS
15. OIL DISCHARGE & DISPOSAL (LINE 14 *$.015)
16. FUEL OIL DISCHARGE ADJUSTMENTS
17. FUEL OIL DISCHARGE TAXABLE GALLONS
18. FUEL OIL DISCHARGE NET GALLONS
19. FUEL OIL DISCHARGE & DISPOSAL (LINE 18 * $.0125)
20. AUTOMOTIVE/MOTOR OIL ADJUSTMENTS
21. AUTOMOTIVE/MOTOR OIL TAXABLE GALLONS
22. AUTOMOTIVE/MOTOR OIL NET GALLONS
23. AUTOMOTIVE OIL FEE (LINE 22 X.$.02)
24. MOTOR OIL DISCHARGE (LINE 22 X $.04)
Net Due (Total of Lines 11, 15, 19, 23, and 24)
$
Signature:
Title:
Date:
(Signed under penalty of unsworn falsification pursuant to RSA 641:3.)
MAKE CHECKS PAYABLE TO: STATE OF NH-ROAD TOLL BUREAU
(SEE REVERSE SIDE FOR INSTRUCTIONS)
RT51 Revised (06/09)
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