Form 8934 Application for Approval of a Mechanical Dye Injection S

Form 8934 | Application for Approval of a | OMB No. 1545-XXXX

(Rev. Nov. 2008) Mechanical Dye Injection System

Part I Applicant Information

Name of individual, corporation, partnership, or other entity Employer identification number (EIN)

___________________________________________________________________________________|________________________

Business name if different from above Telephone number

_____________________________________________________________________________(_______)______________________

Mailing address (number, street, and room or suite no.) Fax number

_____________________________________________________________________________(_______)______________________

City or town, state, and ZIP code Contact person

____________________________________________________________________________________________________________

If your street address is different from your mailing address, list your street address, including the city or town, state and ZIP code.

____________________________________________________________________________________________________________

List the address of the physical location of the facility including the city or town, state and ZIP code.

____________________________________________________________________________________________________________

1. Check the box to show which type of facility operator you are:

 Refiner

 Terminal Operator

 Blender outside of bulk transfer or terminal system

 Operator of facility where fuel is dyed other than one of the above

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2. Provide a brief description of the business activity that relates to this application.

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3. Did you file Form 637, an application to register for certain excise tax activities? □ Yes □ No

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4. List what type of dye you are using in the diesel fuel or kerosene: ______________________

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5. Indicate which method you are using to mechanically inject the dye into the fuel:

 Rack dying sytem. Complete Part II of the application.

 In-tank dying system. Complete Part III of the application.

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Mechanical Dye Injection Systems

Part II Rack Dying System

Rack dyeing is a method of injecting dye into fuel as the fuel is being transferred into

the transport compartment of a truck, trailer, railroad car or other shipping method.

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6. Do you use calibrated devices to measure the amount of dye injected into the fuel?  Yes  No

7. Does the system have automatic shut-off devices in case the system malfunctions?  Yes  No

8. Which method is used to keep the system secure?

A. Unbroken seals with unique identifying numbers or codes secure the measurement devices

or shut-off devices? Yes  No

B. A secured container, such as a lockbox, restricts access to measurement devises, shut-off

devices, and access points and is secured by an unbroken seal?  Yes  No

C. Any security system that provides at least the level of security as (A) or (B) above?  Yes  No

D. There are written procedures that explain how the facility operator should maintain the

system’s security standards?  Yes  No

Cat. No. 37749S

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Part III In-Tank Dyeing

In-tank dyeing is a method of injecting dye while the fuel is in a bulk storage tank or being

delivered to the tank. It can also be injecting dye at a blending facility or while being delivered

to a pipeline or vessel.

9. Does the system measure the volume to be dyed?  Yes  No

10. Does the system calculate the volume of dye necessary to meet the dye

concentration requirements? (See Regulations Section 48.4082-1 for dye

concentration requirements)  Yes  No

11. Does the system add the required volume of dye by a mechanical injection system

that meters the volume of dye so the dye concentration requirements are met?  Yes  No

11. Does the system test the dye concentration in the fuel after the completion of

the dying process?  Yes  No

11. Are records maintained to document compliance with the dye concentration requirments

and show which individuals were involved in the system?  Yes  No

11. Does the system secure the fuel so the dye concentration in the fuel is not reduced

while under the system operator’s control?  Yes  No

Under penalties of perjury, I declare that I have examined this application and to the best of my

knowledge and belief, it is true, correct and complete.

Sign ►_________________________ ► _______________

Here Signature Date

_____________________________________________ ____________________________

Type or print name Title

Form 8934 (Rev. 11-2008)