Form R-9010 - Certification Of Continued Responsibility For Payment Of Oil Spill Contingency Fee

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R-9010 (7/10)
Certification of Continued Responsibility
for Payment of Oil Spill Contingency Fee
(R.S. 30:2451-2496)
Special Programs Division
P.O. Box 4998
Baton Rouge, LA 70821-4998
(225) 219-7656
(225) 219-2114 (TDD)
______________________________________________________________________
Revenue Account Number
____________________________________________________________________________
This certifies that
Name
Address
City
State
ZIP+4
________________________________________________________________________________________
Address
is registered with the Louisiana Department of Reve nue as a marine terminal operator and agrees to remit to the Louisiana Department
of Revenue the oil spill contingency fee on all oil subject to the fee which is picked up from or delivered to:
________________________________________________________________________________________
Name
Address
City
State
ZIP+4
________________________________________________________________________________________
Address
By signing this certification, the terminal operator assumes responsibility for payment of the fee and becomes the party to whom the
Louisiana Department of Revenue will look for payment. The terminal operator accepting this certification should retain it in his records
until all applicable periods have prescribed. A copy must be furnished to the Louisiana Department of Revenue.
Area code and telephone number
Signature
Date

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