Form ECY070-503 "Washington Greenhouse Gas Reporting Program: Transportation Fuel Supplier Report Signature and Submittal Form" - Washington

What Is Form ECY070-503?

This is a legal form that was released by the Washington State Department of Ecology - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2015;
  • The latest edition provided by the Washington State Department of Ecology;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form ECY070-503 by clicking the link below or browse more documents and templates provided by the Washington State Department of Ecology.

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Download Form ECY070-503 "Washington Greenhouse Gas Reporting Program: Transportation Fuel Supplier Report Signature and Submittal Form" - Washington

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GHG Reporting Program: Supplier Report Signature and Submittal Form
Washington Greenhouse Gas Reporting Program:
Transportation Fuel Supplier Report Signature and
SRSS
Submittal Form
Washington State Department of Ecology
Greenhouse Gas Reporting Program
For Ecology Use Only
Date
Air Quality Program
Received:
P.O. Box 47600
Form
Reviewed
Entered
Verified
Olympia, WA 98504-7600
Site ID
ghgreporting@ecy.wa.gov
(360)-407-6811
Web site:
http://www.ecy.wa.gov/programs/air/permit_register/ghg/GHG_transp.html
See the second page of this form for instructions.
1. Report Information – Enter the information below
WA DOL Fuel Tax License ID
Reporting Year
Aggregate CO
(MT)
2
(including nonbiogenic and biogenic CO
)
2
Aggregate Biogenic CO
(MT)
2
2. Supplier Information – Enter the information below
Name
Address
City/State/Zip
NAICS Code(s)
3. Signer Information – Enter the information below
Name
Organization
Mailing Address
City/State/Zip
Phone Number (Ext)
Email Address
4. Parent Company(s) – Enter the information below
Parent Company 1
Parent Company 2
Parent Company 3
Name
Address
City/State/Zip
Percent Ownership
5 .Certification Statement
I am authorized to make this submission on behalf of the owners and operators of the supplier listed
above, for which the submission is made. I certify under penalty of law that I have personally examined,
and am familiar with, the statements and information submitted in this document, electronic submissions,
and all its attachments. Based on my inquiry of those individuals with primary responsibility for obtaining
the information, I certify that the statements and information are to the best of my knowledge and belief
true, accurate, and complete. I am aware that there are significant penalties for submitting false
statements and information or omitting required statements and information, including the possibility of fine
or imprisonment.
6. Signature (sign and date on the lines below)
Signature
Date
To request ADA accommodation, call 360-407-6800, 711 (relay service), or 877-833-6341 (TTY).
ECY 070-503 (rev. 3/15)
Page 1
GHG Reporting Program: Supplier Report Signature and Submittal Form
Washington Greenhouse Gas Reporting Program:
Transportation Fuel Supplier Report Signature and
SRSS
Submittal Form
Washington State Department of Ecology
Greenhouse Gas Reporting Program
For Ecology Use Only
Date
Air Quality Program
Received:
P.O. Box 47600
Form
Reviewed
Entered
Verified
Olympia, WA 98504-7600
Site ID
ghgreporting@ecy.wa.gov
(360)-407-6811
Web site:
http://www.ecy.wa.gov/programs/air/permit_register/ghg/GHG_transp.html
See the second page of this form for instructions.
1. Report Information – Enter the information below
WA DOL Fuel Tax License ID
Reporting Year
Aggregate CO
(MT)
2
(including nonbiogenic and biogenic CO
)
2
Aggregate Biogenic CO
(MT)
2
2. Supplier Information – Enter the information below
Name
Address
City/State/Zip
NAICS Code(s)
3. Signer Information – Enter the information below
Name
Organization
Mailing Address
City/State/Zip
Phone Number (Ext)
Email Address
4. Parent Company(s) – Enter the information below
Parent Company 1
Parent Company 2
Parent Company 3
Name
Address
City/State/Zip
Percent Ownership
5 .Certification Statement
I am authorized to make this submission on behalf of the owners and operators of the supplier listed
above, for which the submission is made. I certify under penalty of law that I have personally examined,
and am familiar with, the statements and information submitted in this document, electronic submissions,
and all its attachments. Based on my inquiry of those individuals with primary responsibility for obtaining
the information, I certify that the statements and information are to the best of my knowledge and belief
true, accurate, and complete. I am aware that there are significant penalties for submitting false
statements and information or omitting required statements and information, including the possibility of fine
or imprisonment.
6. Signature (sign and date on the lines below)
Signature
Date
To request ADA accommodation, call 360-407-6800, 711 (relay service), or 877-833-6341 (TTY).
ECY 070-503 (rev. 3/15)
Page 1
GHG Reporting Program: Supplier Report Signature and Submittal Form
Instructions
Complete this form by typing, then printing; or by printing, then writing legibly in blue or black ink.
Then mail it to the following address by the reporting deadline. Attach additional sheets if more space is
needed.
Washington State Department of Ecology
Greenhouse Gas Reporting Program
Air Quality Program
P.O. Box 47600
Olympia, WA 98504-7600
Transportation fuel suppliers must submit their reports by October 31 of the following year.
Contact Ecology at
ghgreporting@ecy.wa.gov
or (360)-407-6811 if you have questions.
1. Report Information
WA DOL Fuel Tax License ID
Your license number can be found here:
http://www.dol.wa.gov/about/ftactivelists.html
Reporting Year:
The calendar year in which the fuel was supplied.
Aggregate CO
(MT)
Your total emissions for the license for the year.
2
(including nonbiogenic and biogenic
Calculate using the
Transportation Fuel Supplier Calculation
Tool.
CO
)
2
Aggregate Biogenic CO
(MT)
Your total emissions from ethanol and biodiesel for the license for the year.
2
Calculate using the
Transportation Fuel Supplier Calculation
Tool.
2. Supplier Information
Name
Company name on your DOL license.
Address
Address on your DOL license.
City/State/Zip
NAICS Code(s)
All NAICS code(s) that apply to the supplier, beginning with the primary
NAICS code.
http://www.census.gov/eos/www/naics/
3. Signer Information
Name
Individual signing this form. This person must have also submitted a
Certificate of Representation
for this supplier.
Organization
Signer’s employer.
Mailing Address
Signer’s address.
It will be used for correspondence and billing.
City/State/Zip
Phone Number (Ext.)
Signer’s phone number. Optionally, you can also list fax number.
Email Address
Signer’s email address.
4. Parent Company(s)
Name
Highest-level United States parent company(s) of the supplier.
List as many as applicable.
Address
Parent company’s physical address.
City/State/Zip
Percent Ownership
Percentage of ownership interest for each listed parent company as of
December 31 of the reporting year.
5 .Certification Statement
Certification Statement
Read the certification statement.
6. Signature
Signature
Sign the form.
Date
Date form was signed.
ECY 070-503 (rev. 3/15)
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