R-9016-L (10/01)
State of Louisiana
Department of Revenue
Severance Tax Division
Post Office Box 201
Baton Rouge, LA 70821-0201
Registration Application for Oil Spill Contingency Fee
Name ______________________________________________________________________________
Mailing address ______________________________________________________________________
Location address _____________________________________________________________________
Area code and telephone number ________________________________________________________
Contact person ______________________________________________________________________
Briefly describe below your operations as they relate to the handling of crude oil:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Average number of barrels unloaded monthly: _______________________ domestic
_______________________ foreign
Average number of barrels loaded monthly:
_______________________ delivered within Louisiana
_______________________ exported
FOR OFFICE USE ONLY
________________________________________________________
Signature of applicant