AttachmentC-NYSEnvironConservation.pdf

New York State Department of Environmental Conservation Division of Management and Budget

Major Petroleum License Fee Secondary Transfer Certificate revised 2/2/2017

Instructions:

1st Recipient MOSF (Transferor): Complete Parts A and B, give to transferee and retain a copy for your records. This form must accompany each shipment. A barrel is forty two Unites States gallons at 60 degrees Fahrenheit.

Transferee: Retain for your records. The Transferee, if a licensed MOSF, must pay the monthly license fee on all petroleum subject to the monthly license fee unless provided with a properly completed Secondary Transfer certificate by the Transferor. If applicable, fill out the next section for subsequent transfers (downstream customer). All parties of subsequent transfers must keep this form on file in its entirety.

Part A Transferor - First Recipient MOSF Company Name: _________________________________________________ Address: ________________________________________________________ City, State, Zip Code: _____________________________________________

MOSF license number: ______________________ *Terminal Address: ________________________________________________ *Terminal City, State, Zip Code: ______________________________________

Date Product transferred: _____________________ Product type: ______________________________________ Volume (Select One) Barrels/Gallons at 60 degrees Fahrenheit: ___________________ How product transferred: ____Pipeline ____ Barge ____ Truck

____ Other: please specify: ____________

Part B - Transferee:

Transferee Company Name: _______________________________________ Delivery Address: _______________________________________________________ City, State, Zip Code: ____________________________________________

I, the Transferor, have read the instructions and Rules and Regulations promulgated pursuant to Article 12 of the Navigation Law of the State of New York with respect to the use of Major Petroleum Facility License Fee Secondary Transfer Certificate. I certify that the monthly license fee and surcharge have been duly paid or will be paid on product transferred noted above. It is my belief that the Transferee is not required to pay the License Fee on the transaction(s) covered by this certificate. The undersigned Transferor hereby swears (under the penalties of perjury and false swearing) that all the information shown above is true and correct.

Name of Authorized Officer of Transferor Title

Signature Date Federal Employer ID No.

* For on-shore facilities only. For vessel to vessel transfers, leave blank

Attachment C

Part C – Transferor (Transferee from Part B):

Company Name: _________________________________________________ Terminal Address: ________________________________________________________ City, State, Zip Code: _____________________________________________

Licensed MOSF?

______Yes MOSF License Number: ________________ ______No: Please indicate facility type:____ PBS Facility: PBS#_______ _____Barge ____Trucking Company ____Other: please specify________________________________ Date Product Transferred: _____________________ Product Type: ______________________________________ Volume (Select One) Barrels/Gallons at 60 degrees Fahrenheit: ___________________ How product transferred: ____Pipeline ____ Barge ____ Truck ____ Other: please specify: ______________________

Transferee (Third Recipient):

Transferee Company Name: _______________________________________ Delivery Address: _______________________________________________________ City, State, Zip Code: ____________________________________________

I, as the previous Transferee, certify under penalty of perjury, that the information contained in this report is true, complete and correct to the best of my knowledge.

Signature _______________________ Print Name_________________________ Title _______________

Date ___________ Federal Employer ID No._______________________

Part D – Transferor (Transferee from Part C):

Company Name: _________________________________________________ Terminal Address: ________________________________________________________ City, State, Zip Code: _____________________________________________

Licensed MOSF?

______Yes MOSF License Number: ________________ ______No: Please indicate facility type: ____ PBS Facility: PBS#_______ _____Barge ____Trucking Company ____Other: please specify________________________________ Date Product Transferred: _____________________ Product Type: ______________________________________ Volume (Select One) Barrels/Gallons at 60 degrees Fahrenheit: ___________________ How product transferred: ____Pipeline ____ Barge ____ Truck ____ Other: please specify: ______________________

Transferee (Fourth Recipient):

Transferee Company Name: _______________________________________ Delivery Address: _______________________________________________________ City, State, Zip Code: ____________________________________________

I, as the previous Transferee, certify under penalty of perjury, that the information contained in this report is true, complete and correct to the best of my knowledge.

Signature _______________________ Print Name__________________________ Title _______________

Date ___________ Federal Employer ID No._______________________