Form Wv/mft-App - West Virginia Motor Fuel Excise Tax License Application (Page 2 of 4) in pdf

roduct

nformAtion

Check the type(s) of product you will be handling.

 150 – #1 Fuel Oil

 124 – Gasahol

 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 – Produce Code ____________

 122 – Blending Components

 160 – Diesel – Undyed

 054 – Propane

Produce Type_______________________

urchAse

eceipt

nformAtion

(Attach additional pages if necessary.)

Provide the following information on all suppliers from whom you will purchase motor fuel/alternative fuel and on all exchange partners from whom you will receive motor fuel/alterna-

tive fuel from inside the terminal transfer system.

supplier

Point of Origin

Point of Destination

Product

Name

Code

City

State

City

State

supplier

Point of Origin

Point of Destination

Product

Name

Code

City

State

City

State

erminAl

perAtor

nformAtion

If you own, operate, or otherwise control a terminal, you must complete this section.

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

roducer

AnufActure or

efinery

nformAtion

(Attach additional pages if necessary.)

If you own, operate, or otherwise control facilities with producer/manufacturing or petroleum – refining capabilities in West Virginia, you must complete this section.

1. Location Street Address

City

State

Zip Code

2. Provide the product code and estimated number of gallons for each product you plan to produce/manufacture monthly.

Product Code

Gallons

Product Code

Gallons

Product Code

Gallons

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