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T ONLY FORM 4776 (REV. 11-2005) ULTIMATE VENDOR NAME TELEPHONE NUMBER ADDRESS Print Form DLN P.O. BOX FEIN OR SOCIAL SECURITY NUMBER CITY STATE ZIP PRODUCT CODE 065 Gasoline 123 Alcohol 124 Gasohol 125 Aviation Gasoline 130 Jet Fuel 142 Kerosene 072 Dyed Kerosene 160 Diesel Fuel 228 Dyed Diesel Fuel SALES INFORMATION Federal Government Agency 284 Bio-Diesel Undyed B100 285 Soy Oil 290 Bio-Diesel Dyed B100 Date of Sale 122.

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