Free TC-364A - Utah

Special Fuel Supplier Schedule of Receipts
Company name Account number FEIN Schedule Types 1. 2a. Gallons received Utah tax paid (Enter on lines 6 and 12, TC-364) Gallons of dyed diesel received (Enter on line 3, TC-364) Check Product Types 122 Blend components (includes transmix) 142 Kerosene 160 Diesel fuel - undyed 161 Low sulfur diesel #1 - undyed 167 Low sulfur diesel #2 - undyed 150 #1 Fuel oil - undyed

Clear form
Schedule type

TC-364A Rev. 7/97

Month/Year

175 Residual fuel oil 226 High sulfur diesel fuel - dye added 227 Low sulfur diesel fuel - dye added 228 #1 Diesel - dye added

Gallons received on exchange 2b. (Enter on line 7, TC-364) 2c. Gallons of blend product (Enter on line 4, TC-364) 3. Gallons imported from state of ________ (Enter on line 5, TC-364)

Carrier name

Mode

Point of origin

Destination

Seller's name

Seller's FEIN

Date shipped

Document number Invoice number Bill-of-lading

Net gallons

Gross gallons

Billed gallons

TOTALS
T364A.FRM