Form 150-608-001 - Oregon Petroleum Load Fee Registration For Oregon Business Identification Number (Bin)

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Oregon Petroleum Load Fee Registration
FOR OFFICE USE ONLY
Date received
for
Oregon Business Identification Number (BIN)
Business identification number (BIN)
• Print or type all information.
Business name
Federal employer identification number (FEIN)
(including dba)
Business address—street (bulk facility location)
City
State
ZIP code
County
Mailing address—street
City
State
ZIP code
Business telephone number
(
)
Location of business records
City
State
ZIP code
Records telephone number
(if different from above)
(
)
Daytime telephone number
E-mail address
Contact person
Date business started
Type of petroleum products association
Bulk facility
Importer
Bulk facility / seller
Seller
If you are a bulk facility only (not a seller), list your customers in the spaces provided. Use back of form if needed.
1
4
2
5
3
6
Type of Organization
Sole proprietor
Partnership
Corporation
LLC —
Organized as a sole proprietor
Organized as partnership
___________________________
Other
Organized as a corporation
Names of owners, partners, or corporation officers. Please print clearly:
Name
Street address
City, state, ZIP code
Social security number
Approximate number of petroleum loads withdrawn per quarter ________________________
Approximate number of petroleum loads imported per quarter _________________________
This information will be used primarily by the Oregon Department of Revenue for identification and compliance purposes in the
administration of programs related to hazardous materials.
Under penalty of false swearing, I declare the information in this document and any attachments is true, correct, and complete.
Signature
Date
X
PRINT name signed above
Title
Daytime telephone number
(
)
Petroleum Load Fee
Mail to:
Oregon Department of Revenue
PO Box 14110
Salem OR 97309-0910
503-947-2255
Or fax to:
150-608-001 (Rev. 03-11)

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