COMPTROLLER OF MARYLAND
FIELD ENFORCEMENT DIVISION
P.O. BOX 2397, ANNAPOLIS, MD 21404-2397
410-260-7388, 888-674-0017 (Toll-Free), 410-974-5564 (Fax)
APPLICATION FOR REGISTRATION OF TERMINAL AGREEMENT AND ADDITIVES
(In accordance with Business Regulation Article, §10-305 through §10-309 and regulations pertaining thereto.)
Name of Terminal Owner/Operator
Street Address
Federal ID #
Phone #
City
State
Zip
Indicate the period of the terminal agreement:
From
To
INFORMATION REQUIRED FOR EACH GRADE OF GASOLINE AND MIDDLE DISTILLATE FUELS
List the person, firm or corporation with who you have terminalling or "thru-put" agreements supplying the State of
Maryland, along with the products by grade. (Use a separate form for each location.)
Storage
Terminal or Thru-Put for (Company)
Location (City)
Product & Grade
Separate
Co-Mingled
Additives introduced (by product and grade) by terminal operators after product is received into storage or at the time
of shipment. Gasoline additives may only be introduced by a terminal operator who is also a registered refiner.
Additive Designation
Product
Grade
How Injected, At What Point and Amount
File this information annually by December 31 to reflect the next year's established activity. File additional terminal
agreements as they occur throughout the year, using this form. Report deletions as they occur, by letter, to the
Field Enforcement Division.
I certify under the penalties of perjury that this TERMINAL AGREEMENT has been examined by me and to the best
of my knowledge is true, correct and complete, covering the terminalling shown hereon by the parties indicated.
TERMINAL OWNER/OPERATOR
Signature
Date
Name and Title (please print)
TERMINAL PARTNER
Name of Person, Firm or Corporation
Street Address
Federal ID #
Phone #
City
State
Zip
Signature
Date
Name and Title (please print)
COT/FED-305 Rev. 1/10