Free 810ftg-7-03.p65 - California

BOE-810-FTG (7-03)

STATE OF CALIFORNIA

GENERIC RECEIPT SCHEDULE
(If additional space is needed, please photocopy the schedule before making entries.)

BOARD OF EQUALIZATION Page of
(e) MONTH/YEAR

(a) COMPANY NAME

(b) ACCOUNT NUMBER

(c) SCHEDULE CODE

(d) PRODUCT CODE

(1) CARRIER NAME

(2) CARRIER FEIN

(3) MODE

(4) POINT OF ORIGIN (TCN or State/Province) DESTINATION (TCN or State/Province)

(5) ACQUIRED FROM (Seller's Name)

(6) SELLER'S FEIN

(7) DOCUMENT DATE

(8) DOCUMENT NUMBER

(9) NET GALLONS

(10) GROSS GALLONS

(11) BILLED GALLONS

TOTAL
CLEAR

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