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Phone: 503-823-7300

TTY : 503-823-6868

1900 SW 4th Ave, Portland, OR 97201

Qualifying Feedstock Origin Declaration Form
To print a PDF version of this form and fax the completed form and required attachments to
Ross Turkus | Email: crystle.cowen@portlandoregon.gov| Fax: (503) 823-7915.

The City of Portland monitors and studies biodiesel production, use, and sales in the City of Portland. Information collected from this form and other required documentation, identified in item 5 below, will be used to verify that the qualifying feedstock requirements have been met under Portland’s Renewable Fuel Standard (RFS) and PCC16.60.020: when selling or dispensing biodiesel to the Portland market, 50% by volume of the biodiesel must be produced from qualifying feedstock.

Reporting will occur on a quarterly basis for each calendar year. Reports are to be submitted quarterly. The City of Portland will determine compliance through annual compilation of information submitted in quarterly reports, which will occur after the close of the 4th quarter.

Completed reports must be delivered to the City of Portland within 15 days of the last day of the reporting period as identified in the table below:
Qualifying Feedstock Reports Due*
Please complete and submit this form on or before the due date above.
Bulk Facility or Fuel Marketer Name
Mailing Address
Location Address
Marketers may authorize a Bulk Facility to complete part or all of the information requested below by completing the following.
Fuel Marketer Name
Authorizes Bulk Facility Name
Mailing Address
Location Address
Please identify which information is being provided by the Bulk Facility by selecting each number that corresponds with the questions answered below.

Hold Ctrl to select multiple items
1. Total gallons of B99 or higher received by your company for use during the current compliance period. *
2. Total gallons of B5 sold or distributed to the Portland market.*
3. 5% of the total gallons of B5 sold or distributed to the Portland market [Multiply line 2 above by 0.05]*
4. 50% of the number of gallons on line (3) above. [Multiply line 3 above by 0.5]*
5. Attach declaration evidence digitally
(Maximum file size: 30MB)
Send digitally or by fax, evidence of obtaining volume(s) of biodiesel produced from qualifying feedstock (in gallons) equal to the number of total gallons on line (D). For each delivery of biodiesel from qualifying feedstock, evidence could include invoices, shipping documentation, and purchase receipts, detailing :

a. The qualifying feedstock source for the biodiesel obtained;
b. The quantity of the delivery (in gallons); and
c. The date and location of the delivery

The source of the Qualifying Feedstock and the sales and distribution levels cited above must be documented; and the City may inspect records to verify the origin of the feedstock and or/the sales and distribution levels.

The forms shall be submitted to the City of Portland as attachments to the online Declaration form, or by email to ross.turkus@portlandoregon.gov or via FAX at (503) 823-4500.
Print Name of Representative*
Representative Phone Number*
Date*
* Required Field