Biofuel Production Facility Registration

							                                     Pennsylvania Department of Agriculture
                                            Biofuel Production Monthly Report

            PRODUCER INFORMATION                                                                   PDA USE ONLY
            Full Legal Business Name
                                                                                                   Site Identification #

            Mailing Address
SECTION A




            City                                                                                State         Zip Code

            PRODUCTION FACILITY ADDRESS
            Address

            City                                                                                State         Zip Code


            REPORTING PERIOD
SEC. B




            From (mm/dd/yyyy)                                     To (mm/dd/yyyy)


            PRODUCTION DATA
            Type of Fuel Produced (Select One)        Biodiesel           Cellulosic Ethanol

            1. Beginning physical inventory (in gross gallons)                                     1.
            2. Gallons Produced                                                                    2.
            3. Gallons imported into facility from other Pennsylvania locations                    3.

            4. Gallons imported into facility from outside Pennsylvania                            4.
SECTION C




            5. Gallons sold or blended                                                             5.

            6. Ending physical inventory (in gross gallons)                                        6.
            7. Type of agricultural commodity consumed in the facility for production of fuel      (a)
                                                                                                   (b)
                                                                                                   (c)
                                                                                                   (d)
            8. Other types of commodity consumed in the facility for the production of fuel        (a)
                                                                                                   (b)
                                                                                                   (c)
                                                                                                   (d)




 Pennsylvania Department of Agriculture                                                                  Revised 10/21/2008
Biofuel Production Facility Monthly Report                                                                                 Page 2 of 2


            CERTIFICATION
            I verify that the information provided in this document is true and accurate. I understand that I may be subject to
            the criminal penalties prescribed by the Crimes Code (at 18 Pa.C.S.A. Section 4904) for unsworn falsification to
            authorities if there are false statements in this document. That crime carries a jail term of up to 5 years, and a fine
            of between $1,000 and $5,000. Being aware of the possibility of criminal prosecution relating to false statements, I
SECTION D




            hereby verify that the information provided in this document is true and accurate.
            Preparer Printed Name                                 Phone No.
                                                                  (    )     -      Ext.
            Preparer Title


            Preparer Signature                                    Date: (mm/dd/yyyy)




            FILING PROCEDURES
            Reports cover calendar months, eg. January 1 – January 31. The facilities production must be reported to the
            Pennsylvania Department of Agriculture by the 15th day of the following month.

            You may file your monthly production report by mailing or emailing a signed PDF document to
            ag-biofuels@state.pa.us. If you e-mail your signed report, you must mail the original by the 1st day of the following
SECTION E




            month. You may mail your report to the Department at the following address:

            Pennsylvania Department of Agriculture
            Bureau of Ride and Measurement Standards
            Weights and Measures Division
            2301 N. Cameron Street
            Harrisburg, PA 17110

                   If you require assistance in completing this form, you may contact the department at (717) 787-9089.




 Pennsylvania Department of Agriculture                                                                            Revised 10/21/2008