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Special Fuel Supplier Schedule of Disbursements Clear form TC-364B Rev. 7/97 Company name Account number FEIN Schedule type Month/Year Schedule Types Check Product Types 122 Blend components (includes transmix) 175 Residual fuel oil 5. Gallons removed tax collected 226 High sulfur diesel fuel - dye added 142 Kerosene Gallons of dyed diesel and dyed heating 6f. fuel removed (Enter on line 10, TC-364) 227 Low sulfur diesel fuel - dye added 160 Diesel fuel - undyed Gallons exported to state of _________ 7. (Enter on line 9, TC-364) 161 Low sulfur diesel #1 - undyed 228 #1 Diesel - dye added Gallons delivered to Division of Air Quality certificate 10a. holders - suppliers must keep a copy of the certificate 167 Low sulfur diesel #2 - undyed on file (Enter on line 11, TC-364) Gallons exchange disbursements 10b. 150 #1 Fuel oil - undyed (Enter on line 13, TC-364) Document number Net Gross Billed Carrier name Mode Point of origin Destination Buyer's name Buyer's FEIN Date shipped Invoice number Bill-of-lading gallons gallons gallons TOTALS T364B.FRM

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  • 1. Special Fuel Supplier Schedule of Disbursements Clear form TC-364B Rev. 7/97 Company name Account number FEIN Schedule type Month/Year Schedule Types Check Product Types 122 Blend components (includes transmix) 175 Residual fuel oil 5. Gallons removed tax collected 226 High sulfur diesel fuel - dye added 142 Kerosene Gallons of dyed diesel and dyed heating 6f. fuel removed (Enter on line 10, TC-364) 227 Low sulfur diesel fuel - dye added 160 Diesel fuel - undyed Gallons exported to state of _________ 7. (Enter on line 9, TC-364) 161 Low sulfur diesel #1 - undyed 228 #1 Diesel - dye added Gallons delivered to Division of Air Quality certificate 10a. holders - suppliers must keep a copy of the certificate 167 Low sulfur diesel #2 - undyed on file (Enter on line 11, TC-364) Gallons exchange disbursements 10b. 150 #1 Fuel oil - undyed (Enter on line 13, TC-364) Document number Net Gross Billed Carrier name Mode Point of origin Destination Buyer's name Buyer's FEIN Date shipped Invoice number Bill-of-lading gallons gallons gallons TOTALS T364B.FRM