Form L-2191 - Motor Fuel Manufacturer License Application Biodiesel/substitute Fuels
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2STATE OF SOUTH CAROLINA
1350
1350
DEPARTMENT OF REVENUE
L-2191
MOTOR FUEL MANUFACTURER LICENSE
(Rev. 12/19/07)
4347
APPLICATION BIODIESEL/SUBSTITUTE FUELS
PLEASE PRINT OR TYPE ALL INFORMATION
OWNER, PARTNERSHIP, OR CORPORATE
Office Use Only
PHYSICAL LOCATION OF BUSINESS REQUIRED (NO P O BOX)
SID NUMBER
STREET
FILE NUMBER
CITY
COUNTY (REQUIRED)
STATE
ZIP
OPEN DATE
MAILING ADDRESS (FOR ALL CORRESPONDENCE)
IN CARE OF
TRADE NAME (DOING BUSINESS AS)
STREET
BUSINESS PHONE NUMBER
DAYTIME PHONE
CITY
COUNTY (REQUIRED)
STATE
ZIP
FEDERAL IDENTIFICATION NUMBER
PLEASE PRINT OR TYPE ALL INFORMATION
TYPE OF OWNERSHIP
SOLE PROPRIETOR (one owner)
PARTNERSHIP (two or more owners, other than LLP)
UNINCORPORATED ASSOCIATION, ENTER LEGAL NAME
FOREIGN CORPORATION (ATTACH COPY OF ARTICLES OF CERTIFICATE OF AUTHORITY)
SOUTH CAROLINA CORPORATION DATE INCORPORATED
OTHER (EXPLAIN)
LLC/LLP FILING AS:
CORPORATION
PARTNERSHIP
SINGLE MEMBER (Circle One)
NAME OF BUSINESS OWNER, GENERAL PARTNERS, OFFICERS OR MEMBERS:
SECURITY NUMBER
NAME/TITLE/GENERAL PARTNERS
HOME ADDRESS
If Partner
FOR OFFICE USE ONLY
License Code
Report Code
Fee Amount
Bond Amount
Approved by:
30 DAYS ARE REQUIRED FOR PROCESSING A LICENSE APPLICATION
IMPORTANT - THE BACK OF THE APPLICATION MUST BE COMPLETED (IF APPLICABLE) AND SIGNED
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