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Utah State Tax Commission

Environmental Assurance Fee Exemption Certificate
Name of business or institution claiming exemption (purchaser) Street address City Telephone number State

TC-721E Rev. 6/98

ZIP Code

Name of Vendor or Supplier:

I certify to the following: 1. I am the consumer and/or retailer of all petroleum products I will purchase; 2. I own or lease the stationary storage tanks where the petroleum products are stored; 3. None of these storage tanks are covered by the Department of Environmental Quality' s Environmental Assurance Program; and 4. This exemption certificate applies ONLY to purchases made directly from a refinery or a direct import for which the fee has not previously been imposed. I certify that I/we meet all the requirements above for exemption from the Environmental Assurance Fee.
Authorized signature X Date signed Title

Questions should be directed (preferably in writing) to Customer Service, Utah State Tax Commission, 210 N 1950 W, SLC Utah 84134, Telephone (801) 297-2200, or toll free 1-800-662-4335.
To be valid this certificate must be filled in completely, with signature and date.

DO NOT SEND THIS CERTIFICATE TO THE TAX COMMISSION
NOTE TO VENDOR -- Keep this certificate on file since it must be available for audit review. NOTE TO PURCHASER: -- Keep a copy of this certificate for your records. You are responsible to no tify the vendor of cancellation, modification, o r limitation of the exemption you have claimed.
If you need an a ccommodation under the Americans with Disabilities A ct, contact the Tax Commission at (801) 297-3811 or TDD (801) 297-3819. Please allow three working days for a response.