Terminal Operator'S Report Pipeline Reporting
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1Terminal Operator's Report
Pipeline Reporting
Company Name
License Number
Reporting Period
Mail Report to: South Dakota Department of Revenue
445 E Capitol Ave
Pierre, SD 57501-3100
Report in whole gross gallons only
Check Here if this is an amended report
Column A
Column B
Column C
Column D
Column E
Column F
Column G
Column H
Column I
Column J
Undyed
100% Ethyl
Dyed Diesel
Diesel &
Dyed
Clear
Jet Fuel
LPG
Gasoline
Alcohol
AVGAS
& Kerosene
Kerosene
Biodiesel
Biodiesel
Other
Supplier Name
Supplier License Number
1
a
a
Gallons withdrawn by this supplier with a destination in SD
b
b
Gallons withdrawn by this supplier with a destinaion outside SD
c
c
Total gallons withdrawn by this supplier (add lines 1a & 1b)
Supplier Name
Supplier License Number
2
a
a
Gallons withdrawn by this supplier with a destination in SD
b
b
Gallons withdrawn by this supplier with a destinaion outside SD
c
c
Total gallons withdrawn by this supplier (add lines 2a & 2b)
Supplier Name
Supplier License Number
3
a
a
Gallons withdrawn by this supplier with a destination in SD
b
b
Gallons withdrawn by this supplier with a destinaion outside SD
c
c
Total gallons withdrawn by this supplier (add lines 3a & 3b)
Supplier Name
Supplier License Number
4
a
a
Gallons withdrawn by this supplier with a destination in SD
b
b
Gallons withdrawn by this supplier with a destinaion outside SD
c
c
Total gallons withdrawn by this supplier (add lines 4a & 4b)
Supplier Name
Supplier License Number
5
a
a
Gallons withdrawn by this supplier with a destination in SD
b
b
Gallons withdrawn by this supplier with a destinaion outside SD
c
c
Total gallons withdrawn by this supplier (add lines 5a & 5b)
Attach additional sheets if necessary
6
Totals
a
a
Total gallons withdrawn by all suppliers with a destination in SD
(add lines 1a, 2a, 3a, etc and, if necessary, information from additional sheets)
b
b
Total gallons withdrawn by all suppliers with a destination outside SD
(add lines 1b, 2b, 3b, etc and, if necessary, information from additional sheets)
c
c
Grand total gallons withdrawn by all suppliers for this reporting period
(add lines 6a and 6b)
I declare and affirm under penalty of perjury that this report has been examined by me, and to the best of my knowledge and belief is in all true and correct
Printed Name
Signature
Title
Date
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Parent category: Financial