Form Rt 50 - Application For Oil Disharge & Oil Polution Control License - Departament Of Safety Road Toll Bureau, State Of New Hampshire

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FOR OFFICE USE ONLY
LICENSE NO.___________
DATE ISSUED __________
STATE OF NEW HAMPSHIRE
BY___________________
DEPARTMENT OF SAFETY
ROAD TOLL BUREAU
CANCELLED____________
33 HAZEN DRIVE, CONCORD NH 03305
BY___________________
(603) 271-2311
APPLICATION FOR OIL DISCHARGE & OIL POLLUTION CONTROL LICENSE
(RSA 146-A and RSA 146-D)
S.S. OR F.E.I NO. _________________________________________
Name__________________________________________ Telephone No.______________________________
Address: _________________________________________________________________________________
No. and Street
City/Town
State
Zip
Location Where Records Will Be Available For Audit:
Address:______________________________________________________________________________________
No. and Street
City/Town
State
Zip
TYPE OF PRODUCT:
ESTIMATED GALLONS PER YEAR:
Gasoline (Automotive)
Gasoline (Aviation)
Diesel Fuel
Jet Fuel
Heating Oil
Other: (List Below)
Signed By____________________________________ Title______________________________
For ___________________________________________________________________________
Applicant
(PLEASE COMPLETE THE REVERSE SIDE OF THIS APPLICATION)
RT 50 (REV. 2/04)

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