ARKANSAS DEPARTMENT OF ENVIRONMENTAL QUALITY DISCLOSURE STATEMENT Instructions for the Completion of this Document: A. Individuals, firms or other legal entities with no changes to an ADEQ Disclosure Statement, complete items 1 through 6 and 19. B. Individuals who never submitted an ADEQ Disclosure Statement, complete items 1 through 5, 7, 8, and 17 through 19. C. Firms or other legal entities who never submitted an ADEQ Disclosure Statement, complete 1 through 5, and 7 through 19. Mail to: ADEQ DISCLOSURE STATEMENT [List Proper Division(s)] 5301 Northshore Drive North Little Rock, AR 72118-5317 Hand Deliver to: ADEQ DISCLOSURE STATEMENT [List Proper Division (s)] 5301 Northshore Drive North Little Rock, AR 72118-5317 1. APPLICANT: (Full Name) 2. SOCIAL SECURITY NUMBER OR TAX I.D. NUMBER: 3. MAILING ADDRESS (Number and Street, P.O.Box Or Rural Route) : 4. CITY, STATE, AND ZIPCODE: 5. (check all that apply.) Individual Permit Corporate or Other Entity License New Application Air Water Certification Modification Hazardous Waste Operational Authority Renewal Application (If no changes from previous disclosure statement, complete number 6 and 19.) Regulated Storage Tank Mining Solid Waste Environmental Preservation and Technical Service 6. Declaration of No Changes: The violation history, experience and credentials, involvement in current or pending environmental lawsuits, civil and criminal, have not changed since the last Disclosure Statement I filed with ADEQ on Signature of Individual or Authorized Representative of Firm or Legal Entity (Also complete #19.) American LegalNet, Inc. www.FormsWorkflow.com 7. Describe the experience and credentials of the Applicant, including the receipt of any past or present permits, licenses, certifications or operational authorization relating to environmental regulation. (Attach additional pages, if necessary.) 8. List and explain all civil or criminal legal actions (except minor traffic violations) by government agencies against the Applicant * in the last ten years including: 1. Administrative enforcement actions resulting in the imposition of sanctions; 2. Permit or license revocations or denials issued by any state or federal authority; 3. Actions that have resulted in a finding or a settlement of a violation; and 4. Pending actions. (Attach additional pages, if necessary.) * Firms or other legal entities shall also include this information for all persons and legal entities identified in sections 9-17 of this Disclosure Statement. American LegalNet, Inc. www.FormsWorkflow.com 9. List all officers of the Applicant. (Add additional pages, if necessary.) NAME: TITLE: SSN: TITLE: SSN: TITLE: SSN: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: 10. List all directors of the Applicant. (Add additional pages, if necessary.) NAME: TITLE: SSN: TITLE: SSN: TITLE: SSN: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: 11. List all partners of the Applicant. (Add additional pages, if necessary.) NAME: TITLE: SSN: TITLE: SSN: TITLE: SSN: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: 12. List all persons employed by the Applicant in a supervisory capacity or with authority over operations of the facility subject to this application. NAME: TITLE: SSN: TITLE: SSN: TITLE: SSN: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: American LegalNet, Inc. www.FormsWorkflow.com 13. List all persons or legal entities, who own or control more than five percent (5%) of the Applicant's debt or equity. NAME: TITLE: SSN: TITLE: SSN: TITLE: SSN: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: 14. List all legal entities, in which the Applicant holds a debt or equity interest of more than five percent (5%). NAME: TITLE: EMPLOYER ID #: TITLE: EMPLOYER ID #: TITLE: EMPLOYER ID #: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: 15. List any parent company of the Applicant. Describe the parent company's ongoing organizational relationship with the Applicant. NAME: STREET: CITY, STATE, ZIP: Organizational Relationship: 16. List any subsidiary of the Applicant. Describe the subsidiary's ongoing organizational relationship with the Applicant. NAME: STREET: CITY, STATE, ZIP: Organizational Relationship: American LegalNet, Inc. www.FormsWorkflow.com 17. List any person who is not now in compliance or has a history of noncompliance with the environmental laws or regulations of this state or any other jurisdiction and who through relationship by blood or marriage or through any other relationship could be reasonably expected to significantly influence the Applicant in a manner which could adversely affect the environment. NAME: TITLE: SSN: TITLE: SSN: STREET: CITY, STATE, ZIP: NAME: STREET: CITY, STATE, ZIP: 18. List all federal environmental agencies and any other environmental agencies outside this state that have or have had regulatory responsibility over the Applicant. American LegalNet, Inc. www.FormsWorkflow.com 19. VERIFICATION AND ACKNOWLEDGEMENT The Applicant agrees to provide any other information the director of the Arkansas Department of Environmental Quality may require at any time to comply with the provisions of the Disclosure Law and any regulations promulgated thereto. The Applicant further agrees to provide the Arkansas Department of Environmental Quality with any changes, modifications, deletions, additions or amendments to any part of this Disclosure Statement as they occur by filing an amended Disclosure Statement. DELIBERATE FALSIFICATION OR OMISSION OF RELEVANT INFORMATION FROM DISCLOSURE STATEMENTS SHALL BE GROUNDS FOR CIVIL OR CRIMINAL ENFORCEMENT ACTION OR ADMINISTRATIVE DENIAL OF A PERMIT, LICENSE, CERTIFICATION OR OPERATIONAL AUTHORIZATION. State of County of I, , swear and affirm that the information contained in this Disclosure Statement is true and correct to the best of my knowledge, information and belief. APPLICANT SIGNATURE: COMPANY TITLE: DATE: SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF 20 NOTARY PUBLIC MY COMMISSION EXPIRES: American LegalNet, Inc. www.FormsWorkflow.com