Page 101 - IRS Business Tax Credits Guide
P. 101

12:51 - 5-Jan-2023
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                             Fileid: … ns/i8933/202212/a/xml/cycle06/source
         The type and rule above prints on all proofs including departmental reproduction proofs. MUST be removed before printing.
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                                              Disposal Operator Certification (continued)
           10 Complete Table 3 below using information that’s consistent with all applicable EPA filings. If there are more than four owners of the geologic
              disposal site or suppliers of qualified carbon oxide, prepare a separate table with all the supplier information and attach it to this model
              certificate.
           11 Check here to attest that all figures in Table 3 conform to all applicable EPA filings .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .
              Table 3 — Information About Disposal
                         Qualified carbon  Qualified carbon   Qualified carbon   Total qualified   All other suppliers   Total metric tons for all
                          oxide supplier   oxide supplier   oxide supplier   carbon oxide from   of nonqualified   carbon oxide suppliers
                           number 1      number 2      number 3      all suppliers  carbon oxide
                                                                    (H)
                                                                   Metric   (I) Metric           (L) Metric
                                 (C)                                        tons                          (M) Metric
                   (A)     (B)         (D)     (E)    (F)    (G)    tons            (J)    (K)     tons
                 Geologic   Metric   Metric  Metric   Metric   Metric   Metric  delivered   stored   Metric   Metric   delivered   tons stored
                                                                                                            (add
                                                                            (add
                                  tons
                 disposal   tons       tons   tons    tons   tons   (add           tons    tons    (add
                 site owner delivered  store  delivered  stored  delivered  stored  columns   columns   delivered  stored  columns   columns (I)
                                  d                                       (C), (E),                        and (K))
                                                                   (B), (D),   and (G))         (H) and (J))
                                                                   and (F))
               1
               2
               3
               4
               5  Total
                 (add lines
                 1 through
                    4)

          Under penalties of perjury, I attest that I am an officer of the company that’s the operator of the subject geologic disposal site or that I have been
          designated by the operating interest owners to prepare and submit this certificate to the IRS on their behalf. I further attest that the above information
          is true and correct.



          Signature and date signed


          Printed or typed name of person signing this report



          Title



          Company’s name and EIN







                                                                                              Model Certificate DISP‐Operator















                                                            -22-               Instructions for Form 8933 (Rev. 12-2022)
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