Form R-5409 - Motor Fuel Excise Tax License Application Page 4
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4R-5409 (7/06)
O. Storage Facility Information (Attach additional pages if necessary.)
Complete the following for motor fuel storage facilities you own and/or lease. (Include facilities that are currently not in use.)
Own
Terminal Control Number
Physical Location
How will motor fuel be
Product
Storage Capacity
(If fuel is stored at a terminal)
(Street Address, City, State)
received? (explain)
Code
(gallons)
kje;rleqrw;lk
Street Address
;laewkjrlaejkwr
ljrtq;el`lkjl
;d
;laksjdfl;ajsdf
dioajs;dlfj
as
City
State
654654
Street Address
645645
64
654654
654645
64
City
State
Lease
Terminal Control Number
Physical Location
How will motor fuel be
Product
Storage Capacity
(If fuel is stored at a terminal)
(Street Address, City, State)
received? (explain)
Code
(gallons)
asdfasdf
Street Address
654654654
6
45
654654
;a
City
State
asdfasdf
Street Address
f;glja;lkdfj
;l
;lkj;laksdjf
;lkj;
;l
City
State
P. Tax Pre-Collection Agreement
Permissive Suppliers must complete this section.
I agree to collect and remit the taxes due to the State of Louisiana on motor fuel that has Louisiana as its destination
state and that was removed from a terminal located in another state.
Authorized Representative’s Name (Please print or type)
Title
;lkj;lkj;lkj;ljl;j;lj;lkj;ljk
;lkj;lj
Authorized Representative’s Signature
Date
12/30/1981
Telephone Number
Fax Number
E-mail Address
(654) 654-6546
64564654656
(546) 546-4654
Q. Certification – All applicants must complete this section
I certify that I have read this application and know and understand its contents and that all the information
herein is true, correct, and complete. I understand it is unlawful to knowingly make a false statement on the application
and that any violation may be prosecuted.
Authorized Representative’s Name (Please print or type)
Title
Authorized Representative’s Signature
Date
10/29/1980
Telephone Number
Fax Number
E-mail Address
(654) 867-9878
1
(654) 654-6546
Page 4
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