Form Dr-156r Draft - Renewal Application For Florida Fuel/pollutants License (Page 5 of 7) in pdf

Form Dr-156r Draft - Renewal Application For Florida Fuel/pollutants License Page 5

DR-156R

R. 01/18

Page 4

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D) Name ___________________________________________________________ SSN

(Individual)

–

Home address ___________________________________________________ FEIN

(Business)

City ___________________________________________________ County ___________State ___________ZIP __________________

Country _________________________Foreign postal code _______ Phone Number ______________ Ext. ____________________

Corporate or business title __________________________________________________________ Interest/Ownership __________%

NOTE: Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the

administration of Florida’s taxes. SSNs obtained for tax administration purposes are confidential under sections 213.053 and

119.071, Florida Statutes, and not subject to disclosure as public records. Collection of your SSN is authorized u nder state

and federal law. Visit the Department’s website at: and select “Privacy Notice” for more information

regarding the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.

14. Private carriers only

List all vehicles added to your fleet that currently do not have cab cards.

Tank Capacity

Make/Model

Year

Vehicle ID Number

(in gallons)

Fuel storage information

15.

A) Do you have a through-put agreement? ......................................................................................... YES NO

B) Do you deliver fuel directly to retail locations? .............................................................................. YES

C) Do you own, operate or lease any bulk storage tanks in Florida? ................................................ YES

If “YES” to C, list all below and indicate whether it is owned or leased:

Tank Capacity

*DEP Number

Physical Location (Address)

Own/Lease

(in Gallons)

* “DEP Number” means the facility identification number assigned by the Florida Department of Environmental Protection to

your location. DEP numbers are not assigned to Natural Gas dealers. (If necessary, attach a separate sheet.)

Form Dr-156r Draft - Renewal Application For Florida Fuel/pollutants License Page 5