Form Dr 7189 - Gasoline/special Fuel Tax Refund Permit Application
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3DR 7189 (03/21/11)
COLORADO DEPARTMENT OF REVENUE
DENVER, CO 80261-0009
(303) 205-8205
GASOLINE/SPECIAL FUEL TAX
REFUND PERMIT APPLICATION
Taxpayer Name (Last, First, Middle) (owner, partners or corporation)
Registration/Permit Number
(Department Use)
Trade Name/Doing Business As (if applicable)
Business Location Address
City
State
□
Mailing Address
Individual
□
General Partnership
□
City
State
Zip
Limited Partnership
□
Corporation
□
City limits in which business is located (if applicable)
County
Government
□
Other (specify): ____________
FEIN or Social Security Number (REQUIRED)
Telephone
(
)
II. Check box of fuel type for which you will request refunds.
□
□
□
Gasoline
Aviation Jet Fuel
Gasohol
□
□
Special Fuel
Aviation Gasoline
Enter total fuel capacity of storage tanks:
Aviation Gasoline ___________________
Aviation Jet Fuel _____________
Gasoline _________________
Special Fuel ________________
III. Circle ONLY ONE classification code that best describes your business. (In the case of multiple uses, circle the
code where the bulk of the fuel is used.) Provide a description of your business in Part IV.
SERVICES–COMMERCIAL
23 Farm/Ranch - Livestock Feedlot Operations
45 Ready Mix Cement Hauling
02 Back county Tour/guide Operations
24 Sod Farm Operations
46 Cement Hauling - Cement Bulker
25 Commercial Nursery & Horticultural Operations
47 Gen Const Prod Hauling - Lumber/Rebar/Etc
03 Carpet & Upholstery Cleaning
04 Cemetery & Crematorium Operations
26 Forestry & Logging Operations
48 Irrigations Systems Operations
27 AG Dealer - Fert/Chem “Custom Appln.”
MINING/OIL & GAS PROD
05 Equipment Rental & Leasing Operations
06 Public Golf Course Operations
CONSTRUCTION
50 Ores & Rock Quarry Operations
08 Recreational Parks/Camp Operations
30 General Construction
51 Coal Mining Operations
09 Marina Operations
31 Highway & Road Construction
52 Sand & Gravel Pit Operations
10 Ski Resort Operations
32 Commercial Building Construction
53 Crude Pet & Natural Gas Prod Facilities
11 Snow Mobile Tour-Rental Operations
33 Construction Excavation & Digging
54 Oil & Gas Exploration & Drilling Operations
13 Mobile Wash Operations
34 Residential Construction
55 Oil & Gas Field Service Operations
14 Waste Disposal Facilities & Operations
35 Water Well Drilling
MANUFACTURING
18 Commercial Avn - Fixed Base Operations
TRANSPORTATION/COMM
60 Manufacturing Operations - General
19 Agricultural Crop Dusting & Spraying
40 Refrigerated Trailers
61 Concrete Prods, Brick, Block Mfg
AGRICULTURE/FORESTRY/FISHING
41 Aviation - Scheduled Air Carriers
62 Sawmill Operations
20 Crops - Grain (Wheat, Corn, Barley, Hay, Etc)
42 Railroad Operations on Rails
63 Recycling & Mfg Operations
21 Crops - Fruits or Vegetables
43 Waste Disposal Hauling - Res/Com
PUBLIC ADMINISTRATION/GOVT
22 Farm/Ranch - Livestock Grazing Operations
44 Sand, Gravel & Aggregate Hauling
99 State, Local, Federal, Public Education, Dists
Signed under penalty of perjury in the second degree.
Individual, partners, corporate or political subdivision name
Applicant signature
Signatures of Other Officers Authorized to Sign Refund Checks
Date
Telephone
(
)
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Parent category: Financial