Form 72a300 - Tax Registration Application For Motor Fuels License (Page 4 of 4) in pdf

Form 72a300 - Tax Registration Application For Motor Fuels License Page 4

SECTION 10—TERMINAL OWNER-OPERATOR INFORMATION

1. Does or will applicant regularly engage in the disbursement of motor fuel from terminal facilities in Kentucky?

 Yes

 No (If yes, complete this section.)

2. Which type of fuel is or will be disbursed?  Gasoline

 Special Fuels

3. List each storage tank used exclusively for terminal disbursement. Gasoline grade includes alcohol, gasoline-alcohol blends, etc.

Special fuels type means dyed (nonhighway use) diesel, undyed (highway use) diesel and kerosene. Attach additional list if necessary.

If tanks and real estate are leased by applicant, attach name and address of owner.

Total

Gasoline

Special Fuels

Terminal Code Number

City

Tank Capacity

(in gallons)

➤ IMPORTANT: APPLICATION MUST BE SIGNED BELOW.

The information contained in this application is hereby certified to be correct to the best knowledge and belief of the undersigned who is

authorized to sign this application. Signature of owner or partners is required. If a corporation, an officer must sign.

Signature

Print Name

Title

Date

Signature

Print Name

Title

Date

Signature

Print Name

Title

Date

Form 72a300 - Tax Registration Application For Motor Fuels License Page 4