Form R-5409 - Motor Fuel Excise Tax License Application Page 2
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4R-5409 (7/06)
E. 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 (specify below)
❐
❐
❐
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_______________________________
122 – Blending Components
160 – Diesel - Undyed
054 – Propane
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
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;ljl;j
kl
lkjlfjaii
;l
Exchange Partner
Point of Origin
Point of Destination
Product
Name
Code
City
State
City
State
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oi
;l;i
io
oi
G. Terminal Operator Information
If you own, operate, or otherwise control a terminal, you must complete Section O.
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 a terminal, you must complete Section O.
1. Refinery Street Address
City
ZIP
State
LA
;lkj;lkj
l;jlkj
80840
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
65
6654654
65
544
5
77
I. Supplier Information. 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 agreement(s)?
❐
❐
Yes
If yes, you must complete Section F- Motor Fuel Purchase/Receipt Information.
No
J. Blender Information (Attach additional pages if necessary.)
If you will blend petroleum products in Louisiana, you must complete this section.
Blending Site Physical Address
City
ZIP
Tank Capacity (gallons)
State
LA
lakdjf;laksdjf
;ljasdl;fj
98798
lakjf;lkajs;dlfjk;als
Provide a complete description of your blending operation.
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;lj;lj;lj;skldfja;osdut;
lask;dha;khsdf;k
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