Form Reg-8-A - Motor Fuel And Other Fuel Information (Distributor, Supplier, Receiver, Or Blender) Page 3

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1 8 Provide the following information on all your suppliers of motor fuel and/or other fuels.
(Attach additional sheets if necessary.)
Company name and address
Phone
Location of receipt (city and state)
___________________________________________________________ (_____)___________________ _____________________________________________________
___________________________________________________________ (_____)___________________ _____________________________________________________
___________________________________________________________ (_____)___________________ _____________________________________________________
___________________________________________________________ (_____)___________________ _____________________________________________________
___________________________________________________________ (_____)___________________ _____________________________________________________
1 9 Tell us all the motor fuel/other fuel license numbers held by your company, from your home state and other states.
(Attach additional sheets if necessary.)
State
Gasoline license number
Special fuel license number
Other license number
Home state _______________________
_______________________
_______________________
_______________________
Other state
_______________________
_______________________
_______________________
_______________________
Other state
_______________________
_______________________
_______________________
_______________________
Other state
_______________________
_______________________
_______________________
_______________________
Other state
_______________________
_______________________
_______________________
_______________________
20 Do you lease Illinois bulk storage tanks/space to another company? Yes
No
If yes, attach a copy of your contract.
Name of lessee ________________________________________________________________________________________________
Volume amount leased ___________________________________________________________________________________________
21 Do you lease Illinois bulk storage tanks/space from another company? Yes
If yes, attach a copy of your contract.
No
Name of lessor ________________________________________________________________________________________________
Volume amount leased __________________________________________________________________________________________
2 2 List the Illinois bulk storage tanks/space you operate. List each storage tank separately.
(Attach additional sheets if necessary.)
Location
Product Type*
Storage Capacity
Above or below ground
Owned or leased
(Street, city, and state)
_____________________________________ _____________ _______________________
above
below
owned
leased
_____________________________________ _____________ _______________________
above
below
owned
leased
_____________________________________ _____________ _______________________
above
below
owned
leased
_____________________________________ _____________ _______________________
above
below
owned
leased
*Gas - Gasoline; GHL - Gasohol; DSL - Diesel; DD - Dyed Diesel; KER - Kerosene; AVI - Aviation/jet fuel; 1-K - 1-K Kerosene; Other - Please specify
23 List the Illinois retail outlets you own or operate. List each retail outlet separately.
(Attach additional sheets if necessary.)
Location
Product Type*
Storage Capacity
Above or below ground
Owned or leased
(Street, city, and state)
_____________________________________ _____________ _______________________
above
below
owned
leased
_____________________________________ _____________ _______________________
above
below
owned
leased
_____________________________________ _____________ _______________________
above
below
owned
leased
_____________________________________ _____________ _______________________
above
below
owned
leased
*Gas - Gasoline; GHL - Gasohol; DSL - Diesel; DD - Dyed Diesel; KER - Kerosene; AVI - Aviation/jet fuel; 1-K - 1-K Kerosene; Other - Please specify
2 4 Do you own fuel transport trucks? Yes
No
If yes, how many? _______
Do you own tank wagons? Yes
No
If yes, how many? _______
2 5 Estimate the number of gallons handled monthly in Illinois:
Gasoline ________________ Special fuel ________________ Dyed Diesel ________________ Other fuels
________________
(specify)
2 6 Describe in detail all of your intended monthly motor fuel/fuel operations in Illinois once licensed.
(Attach a separate sheet if necessary.)
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Page 3
REG-8-A (R-03/13)

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