Free TC-364B - Utah

Special Fuel Supplier Schedule of Disbursements
Company name Account number FEIN Schedule Types 5. Gallons removed tax collected 6f. Gallons of dyed diesel and dyed heating fuel removed (Enter on line 10, 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-364B 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 exported to state of _________ 7. (Enter on line 9, TC-364) Gallons delivered to Division of Air Quality certificate 10a. holders - suppliers must keep a copy of the certificate on file (Enter on line 11, TC-364) 10b. Gallons exchange disbursements (Enter on line 13, TC-364)

Carrier name

Mode

Point of origin

Destination

Buyer's name

Buyer's FEIN

Date shipped

Document number Invoice number Bill-of-lading

Net gallons

Gross gallons

Billed gallons

TOTALS
T364B.FRM