Form Dr-904 Draft - Pollutants Tax Return - 2018 Page 3

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00002
DR-904
R. 01/15
Page 3
(1) Coastal
(4) Water Quality on
(2) Water Quality
(3) Inland Protection
Protection
Perchloroethylene
Schedule A - Solvents
1.
Gallons sold/removed from storage: ......................
1.
2.
Tax-paid gallons and gallons not subject to tax: .....
2.
3.
Export allowance: ...................................................
3.
4.
Net taxable gallons: ................................................
4.
0.059
5.00
5.
Rate per gallon: .......................................................
5.
6.
Tax due: ..................................................................
6.
Schedule B - Motor Oil & Other Lubricants
7.
Gallons sold/removed from storage: ......................
7.
8.
Tax-paid gallons and gallons not subject to tax: ....
8.
9.
Export allowance: ...................................................
9.
10. Net taxable gallons: ................................................
10.
0.025
11. Rate per gallon: .......................................................
11.
12. Tax due: ..................................................................
12.
Schedule C - Ammonia
13. Barrels sold/removed from storage: .......................
13.
14. Tax-paid barrels and barrels not subject to tax: ......
14.
15. Export allowance: ...................................................
15.
16. Net taxable barrels: .................................................
16.
0.02
0.02
17. Rate per barrel: .......................................................
17.
18. Tax due: ..................................................................
18.
Schedule D - Gasoline and Gasohol
19. Barrels sold/removed from storage: .......................
19.
20. Barrels not subject to tax: ........................................
20.
21. Export allowance: ...................................................
21.
22. Net taxable barrels: .................................................
22.
0.02
0.05
0.80
23. Rate per barrel: .......................................................
23.
24. Tax due: ..................................................................
24.
Schedule E- Diesel and Other Pollutants
25. Barrels sold/removed from storage: .......................
25.
26. Tax-paid barrels and barrels not subject to tax: ......
26.
27. Export allowance (see Important Notice, Page 1): ...
27.
28. Net taxable barrels: .................................................
28.
0.02
0.05
0.80
29. Rate per barrel: .......................................................
29.
30. Tax due: ..................................................................
30.
(1) Coastal
(4) Water Quality on
(2) Water Quality
(3) Inland Protection
Protection
Perchloroethylene
31. Credits: (see instructions) .......................................
31.
32. Credit for tax-paid petroleum products transferred
to a registered IRS terminal (see instructions). ........
32.
33. Total tax due: Calculate total tax due by
subtracting your credits (Line 31 plus Line 32) from
33.
the tax due (sum of Lines 6, 12, 18, 24, and 30). ....

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