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Form L-2191 - Motor Fuel Manufacturer License Application Biodiesel/substitute Fuels Page 2

INDICATE S C ANTICIPATED MONTHLY GALLONS

WHOLESALE

RETAIL

INDICATE ANTICIPATED MONTHLY EXPORTS IN GALLONS BELOW

LIST YOUR RETAIL OUTLETS BELOW

LOCATION

RETAIL SALES TAX NUMBER

ADDITIONAL INFORMATION

1. Do you transport your own product?

Yes

No If yes, please enter your Transporter License number

If no, who transports this product?

2. List the states you are licensed to do business in

3. List the exact locations of each place of business where applicant produces or manufactures in this state.

Social Security Privacy Act

It is mandatory that you provide your social security number on this tax form. 42 U. S C 405(c)(2)(C)(i) permits a state to use an individual's social

security number as means of identification in administration of any tax. SC Regulation 117-1 mandates that any person required to make a return to the

South Carolina Department of Revenue shall provide identifying numbers, as prescribed, for securing proper identification. Your social security number

is used for identification purposes.

When signing this form, it is important that the information contained in your report be correct and complete. To willfully

furnish a false or fraudulent statement to the Department is a crime. Section 12-54-44(4)

Signature

Title

Date

Mail this application to SC Department of Revenue, Motor Fuel Section, Columbia, S C 29214 For Assistance call (803)

896-1990.

43472026