Form L-2101 - Motor Fuel Terminal Operator Annual Return
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61350
STATE OF SOUTH CAROLINA
L-2101
DEPARTMENT OF REVENUE
(Rev. 10/15/14)
MOTOR FUEL TERMINAL OPERATOR ANNUAL RETURN
4189
Mail to: SC Department of Revenue, Motor Fuel, Columbia, SC 29214-0132.
This return is due February 26 of the next year.
Operator Name and Address
License Number
FEIN
Terminal Code
Name and Physical Address of Terminal
Year
8
Gasoline User Fee Due
($0.16)
9
Penalty
10
Interest
11
Total Gasoline User Fee Due
34-2301
12
Special Fuel User Fee Due
($0.16)
13
Penalty
14
Interest
15
Total Special Fuel User Fee Due
34-2101
16
Inspection Fees Due
($0.0025)
17
Penalty
18
Interest
19
Total Inspection Fees Due
34-2314
20
Environmental Impact Fees Due ($0.0050)
21
Penalty
22
Interest
23
Total Environmental Impact Fees Due
34-2312
24
Total Fees Due, Plus Penalty and Interest
(Lines 11 + 15 + 19 + 23)
I hereby certify that the information contained in this return (including accompanying schedules and
statements) has been examined by me and to the best of my knowledge is correct and complete.
Name:
Phone:
Date:
(Print)
Signature:
Email:
Page 1
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