Bulk Plant Operator'S Report Transport Load Reporting

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Bulk Plant Operator's Report
Transport Load Reporting
Company Name
License Number
Reporting Period
Mail Report to: South Dakota Department of Revenue & Regulation
445 E Capitol Ave
Pierre, SD 57501-3100
Report in whole gross gallons only
Check Here if this is an amended report
Attach bills of lading for each transport load of 4,200 gallons or more
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Column I
Column J
Undyed
100% Ethyl
Dyed Diesel
Diesel &
Dyed
Clear
Gasoline
Alcohol
AVGAS
& Kerosene
Kerosene
Biodiesel
Biodiesel
Jet Fuel
LPG
Other
Customer Name
Customer License No. (if applicable)
1
a
a
Gallons withdrawn by this customer with a destination in SD
b
b
Gallons withdrawn by this customer with a destinaion outside SD
c
c
Total gallons withdrawn by this customer (add lines 1a & 1b)
Customer Name
Customer License No. (if applicable)
2
a
a
Gallons withdrawn by this customer with a destination in SD
b
b
Gallons withdrawn by this customer with a destinaion outside SD
c
c
Total gallons withdrawn by this customer (add lines 2a & 2b)
Customer Name
Customer License No. (if applicable)
3
a
a
Gallons withdrawn by this customer with a destination in SD
b
b
Gallons withdrawn by this customer with a destinaion outside SD
c
c
Total gallons withdrawn by this customer (add lines 3a & 3b)
Customer Name
Customer License No. (if applicable)
4
a
a
Gallons withdrawn by this customer with a destination in SD
b
b
Gallons withdrawn by this customer with a destinaion outside SD
c
c
Total gallons withdrawn by this customer (add lines 4a & 4b)
Customer Name
Customer License No. (if applicable)
5
a
a
Gallons withdrawn by this customer with a destination in SD
b
b
Gallons withdrawn by this customer with a destinaion outside SD
c
c
Total gallons withdrawn by this customer (add lines 5a & 5b)
Attach additional sheets if necessary
6 Totals
a
a
Total gallons withdrawn by all customers with a destination in SD
(add lines 1a, 2a, 3a, etc and, if necessary, information from additional sheets)
b
b
Total gallons withdrawn by all customers with a destination outside SD
(add lines 1b, 2b, 3b, etc and, if necessary, information from additional sheets)
c
c
Grand total gallons withdrawn by all customers for this reporting period
(add lines 6a and 6b)
I declare and affirm under penalty of perjury that this report has been examined by me, and to the best of my knowledge and belief is in all true and correct
Printed Name
Signature
Title
Date

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