Form Dr-309637 Sample - Petroleum Carrier Information Return - 2015 Page 4

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DR-309637
R. 01/13
Page 4
(mm/dd/yy)
GALLONS
B. Undyed
C. Dyed
1. T
at a F
...........................................................
2. T
F
............................................
3. T
at a F
F
...........................................
4. T
transported (Total of
.....

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