Attachment C - NYSEnvironConservation.pdf
PDF 611 KB Posted
- Solicitation number
- 446918CE
- Issued by
-
Department of Energy Office of Science
About this file
This document is a New York State Department of Environmental Conservation form titled "Major Petroleum License Fee Secondary Transfer Certificate." It provides instructions and a form for the transfer of petroleum products between licensed and unlicensed facilities in the state. The form requires details such as the transferor and transferee company names, license numbers, product types and volumes, transfer methods, and certifications that the monthly license fees have been paid. It includes four parts to accommodate multiple transfers. This form is required to accompany each shipment of petroleum products in New York to ensure proper payment of licensing fees.
The related federal contract opportunity is a Request for Quote (RFQ) from Brookhaven Science Associates (BSA) for the supply of Red-Dyed ULSD Heating Oil, Grade #2 (CSF). The RFQ requires bidders to provide the origin of manufacture and their Unique Entity Identifier (UEI). Quotes are due by 10/25/24. The resulting purchase order will be subject to the attached terms and conditions. The contracting agency is the Department of Energy Office of Science.
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Text version
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 alexander Attachment C alexander
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._______________________
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