1. Clear form
ES-RF
Utah State Tax Commission
Application For Environmental TC -113
Rev. 6/03
Assurance Fee Refund
Telephone: (801) 297-2200 for assistance
(1-800-662-4335 outside Salt Lake City but inside Utah)
Name Federal identification or Social Security no.
Mailing address Filing period (Begin: mmyy End: mmyy)
Begin: End:
City, State, ZIP code
Refund application may not be filed more often than on a monthly basis.
The following conditions are required to file for an Environmental Assurance Fee refund.
1. I was the consumer, retailer and/or exporter of the petroleum products claimed;
2. For a consumer and/or retailer: I owned or leased the stationary storage tank where the gallons claimed were stored;
3. None of the storage tanks where the claimed gallons are stored are covered by the
Department of Environmental Quality’s Environmental Assurance Program; and
4. The Environmental Assurance Fee was paid to my supplier on all gallons claimed.
Purchase invoices and tank throughput records (i.e. inventory records, meter readings, etc.)
should be available for audit for three years from the date of the refund.
Mail to: Utah State Tax Commission
210 N 1950 W
Salt Lake City, UT 84134
Refund Rate Table (Use for line 2 below)
Rate for filing Rate for filing
periods ending prior periods beginning
to or on 6/30/03 on 7/1/03 or later
0.0025
Environmental Assurance 0.0050
Fee Refund Rate or 0.25% or 0.50%
1. Total gallons qualifying for refund (from schedule on back) 1
2. Enter refund rate (see Refund Rate Table above for the correct rate for filing period) 2
3
3. Multiply line 1 by line 2. This is your TOTAL REFUND
I certify that I meet all the conditions to qualify for this refund. I have examined this refund application, including
any accompanying schedules, and certify that to the best of my knowledge it is true, correct and complete.
Signed Date signed Title Telephone
X
If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811
(TDD (801) 297-2020). Please allow three working days for a response.

2. TC-113A
Environmental Assurance Fee Refund Schedule Schedule
Product
Invoice Invoice Number of
Tank Tank location Facility number Supplier type
date number gallons
type
Total Gallons