APPLICANT DISCLOSURE FORM This form must be completed by every Applicant: (1) Seeking an Ohio solid, infectious, or hazardous waste permit, other than a permit modification, or license for an off-site facility; (2) Holding a solid, infectious, or hazardous waste permit or license for an off-site facility; or (3) Who is a prospective owner of an off-site facility. Pursuant to Ohio Revised Code 3734.41 through 3734.47 and Ohio Administrative Code 109:6-1-01 through 109:6-1-05 American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT DISCLOSURE FORM 1. WHO MUST COMPLETE THIS FORM. Any individual, business concern, or governmental entity who qualifies as an applicant under O.A.C. 109:6-1-01(B). As defined by O.A.C. 109:6-1-01, “Applicant” means any person: (1) (2) (3) Seeking a permit, other than a permit modification, or license for an off-site facility; Holding a permit or license for an off-site facility; or A prospective owner of an off-site facility. As defined by O.A.C. 109:6-1-01, “Business concern” means any corporation, association, firm, partnership, trust, sole proprietorship, or other form of commercial organization. 2. ALL QUESTIONS MUST BE ANSWERED. Read every question carefully before you begin answering any question. Answer every question completely. Do not leave any blank spaces. If a question does not apply to you, enter “Not applicable” or “N/A” in the space provided for an answer. If there is nothing to disclose in answer to a particular question, enter “None” in the space provided for an answer. 3. ANSWER COMPLETELY AND TRUTHFULLY. Failure to answer any questions completely may result in your statement being returned to you for supplementation of your answer. If the answer to a question in this form is identical to an answer previously given to a question in the form, you may answer the later question by writing “Same as .” For example, if the answer to Question 3 is the same as the answer to Question 2, you may answer Question 3 by writing “Same as 2”. 4. ADDITIONAL SPACE. If you need additional space to answer a question, use plain 8 ½” x 11” paper. Insert additional pages immediately following the page on which the question you are answering appears. Be sure to indicate that your answer to the question is “continued on next page,” and indicate on the additional page which question is being continued there. When you have finished answering all questions, and have attached all additional pages, consecutively number each page at the top right corner – including the additional pages. Pages of the original form, which need to be renumbered as a result of adding pages, should be renumbered at the space provided after “Your Page No. .” 5. EXHIBITS. If you are required or wish to submit any document in connection with your answer to any question, refer to it in your answer as, for example, “Exhibit No.,” and attach it at the end of the form. 6. TYPE OR PRINT YOUR ANSWERS. Type or print in legible block letter style. Handwritten forms will be returned if entries are in script or are unreadable. DO NOT USE A SCRIPT TYPEFACE. American LegalNet, Inc. www.FormsWorkFlow.com 7. INTERPRETIVE ASSISTANCE IN COMPLETING DISCLOSURE STATEMENTS. If you need interpretive assistance in completing a disclosure statement, you may submit in writing to the Attorney General a regulatory guidance request seeking an informal, non-binding interpretation of a regulatory requirement imposed by Sections 3734.41 to 3734.47 of the Ohio Revised Code and the rules adopted there under. 8. The information required to be submitted in the disclosure statement is intended to be the information necessary to begin the background investigation required by Sections 3743.41 through 3734.47 of the Ohio Revised Code. By signing the Release Form below you agree to allow the Attorney General to check your background for administrative, civil, and criminal violations, your credit history, and report this information to the Ohio EPA. In limiting the scope of information required to be included in the disclosure statement, it is expressly contemplated that in individual investigations, the Attorney General may have reasonable cause to engage in additional review of the Applicant. Nothing contained herein shall be construed to restrict or limit the scope of the information the Attorney General may seek pursuant to the procedures established in Sections 3734.43 of the Ohio Revised Code. IF YOU HAVE GENERAL QUESTIONS ABOUT HOW TO FILL OUT THIS FORM, CALL THE ATTORNEY GENERAL’S OFFICE AT (614) 466-3843. WARNING: FRAUDULENT, DECEPTIVE OR MISLEADING ANSWERS MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE OR PERMIT. IN ADDITION, ANY PERSON WHO KNOWINGLY OR RECKLESSLY MAKES FALSE OR MISLEADING STATEMENTS ON THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION. If you are unsure of, or do not remember the answer to a question, indicate this in some way – for example, by writing “Do not remember.” This may result in additional inquiries from the Director of the Ohio EPA or the Attorney General’s Office, but it will avoid implication that you are trying to conceal information. However, you should not answer “Do not remember,” or with similar words, simply because the information may not be immediately at hand. You are expected to make reasonable efforts to check your records so that you can answer the questions completely. American LegalNet, Inc. www.FormsWorkFlow.com SOCIAL SECURITY NUMBERS Notice required under Section 7(b) of the Federal Privacy Act of 1974 Under Section 7(b) of the Privacy Act of 1974, 5 U.S.C. Section 552a (note), any federal government agency which requests an individual to disclose his Social Security Account Number, must inform that individual whether the disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it. Although not expressly bound by this provision, the Ohio Environmental Protection Agency and the Ohio Attorney General are authorized to request Social Security Numbers pursuant to Paragraph (D) of Section 3734.41 of the Ohio Revised Code, which defines content of the disclosure statements. The Social Security number is used as a secondary identifier by the Ohio Bureau of Criminal Identification and Investigation when they conduct background investigations of individuals listed on disclosure statements. It is used routinely to ensure correct identification when the Bureau of Criminal Identification and Investigation conducts a check of criminal history records maintained by the state and federal governments. In specific investigations which may involve examination of particular records obtained from outside sources, the Social Security Number may be used to determine whether the individual named in the records and the individual under investigation are the same or different persons. The listing of Social Security Numbers on the disclosure forms is voluntary. The State of Ohio will not deny or revoke a license or impose any penalty because of an individual’s refusal to disclose a Social Security Number. However, the absence of a Social Security Number as a secondary identifier may delay processing and decisions on licensure because of necessary additional investigative time. Note that, the absence of a Social Security Number may result in an individual initially being identified as having a criminal record, which actually is that of another person. This again, may result in delays in the decision on licensure required by Ohio Revised Code Section 3734.41 et seq. American LegalNet, Inc. www.FormsWorkFlow.com Page No. 1 Your Page No._____ APPLICANT DISCLOSURE FORM NAME OF PERSON TO BE CONTACTED REGARDING THIS FORM: ________________________________________ ________________________________________ (Name) (Title) CONTACT PERSON’S TELEPHONE NUMBER: (Area Code) 1.a. NAME OF APPLICANT: State the complete name of the Applicant as it appears on the certificate of incorporation, charter, by-laws, partnership agreement or other official document which establishes the name of the Applicant. (If no such document exists, state the name the business uses): ____________________________________________________________________________________ TELEPHONE NUMBER: (Area Code) FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):________________________________ PUBLICLY TRADED CORPORATION: Check one. Yes ______ No ______ SECONDARY BUSINESS ACTIVITY CONCERNS: In each of the past three years, has the Applicant derived less than five percent of its annual gross revenue from the collection, transportation, treatment, storage, recycling, processing, transfer or disposal of solid, infectious, or hazardous waste? Yes ______ No ______ If yes, applicant qualifies as a Secondary Business Activity Concern. Secondary Business Activity Concerns: List the officers, directors, and any other persons who might otherwise be required to file a disclosure statement but do not have responsibility for or control of, the solid, infectious, or hazardous, waste operations of Applicant, and therefore are exempt from filing a Personal History Disclosure Statement and fingerprinting. • Name ________________________________________ Position Held ________________________________________ • Name ________________________________________ Position Held ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 2 Your Page No._____ • Name ________________________________________ Position Held ________________________________________ PAST NAMES OF APPLICANT: List all other names under which the Applicant has been known or done business in the past ten years. • Name ________________________________________ From (year) _______________ To (year) _______________ • Name ________________________________________ From (year) _______________ To (year) _______________ • Name ________________________________________ From (year) _______________ To (year) _______________ 1.b. STREET ADDRESS OF PRINCIPAL OFFICE: _____________________________________________________________________________________ (Number and Street) ___________________________________ _________________________ _______________________ (City) 1.c. (State) (Zip Code) MAILING ADDRESS, IF DIFFERENT: _____________________________________________________________________________________ (Number and Street) ___________________________________ _________________________ _______________________ (City) 1.d. (State) (Zip Code) FACILITIES IN OHIO: List all solid, hazardous, or infectious waste facilities of the applicant that are located in the State of Ohio. • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ U.S. EPA Facility I.D. No. ________________________________________ OEPA Registration No. ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 3 Your Page No._____ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ U.S. EPA Facility I.D. No. ________________________________________ Ohio EPA Registration No. ________________________________________ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ U.S. EPA Facility I.D. No. ________________________________________ Ohio EPA Registration No. ________________________________________ 1.e. FORMER FACILITIES IN OHIO: List all solid, hazardous, or infectious waste facilities formerly owned and/or operated by the applicant in the State of Ohio. • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ Approximate Dates Owned or Operated from (Year) to (Year) ________________________________ U.S. EPA Facility I.D. No. ________________________________________ Ohio EPA Registration No. ________________________________________ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ Approximate Dates Owned or Operated from (Year) to (Year) _______________________________ U.S. EPA Facility I.D. No. ________________________________________ Ohio EPA Registration No. ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 4 Your Page No._____ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ Approximate Dates Owned or Operated from (Year) to (Year) ________________________________ U.S. EPA Facility I.D. No. ________________________________________ Ohio EPA Registration No. ________________________________________ 1.f. FACILITIES IN OTHER JURISDICTIONS: List all locations in any state, district or territory of the United States, other than Ohio, or in any foreign country, at which the Applicant is currently operating a solid, infectious, or hazardous facility. • Name ________________________________________ Address & Telephone Number _________________________________________________________ Facility Type ________________________________________ U.S. EPA Facility I.D. No. (if any) ________________________________________ • Name ________________________________________ Address & Telephone Number _________________________________________________________ Facility Type ________________________________________ U.S. EPA Facility I.D. No. (if any) ________________________________________ • Name ________________________________________ Address & Telephone Number _________________________________________________________ Facility Type ________________________________________ U.S. EPA Facility I.D. No. (if any) ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 5 Your Page No._____ 1.g. FORMER FACILITIES IN OTHER JURISDICTIONS: List all locations in any state, district or territory of the United States, other than Ohio, or in any foreign country, at which the Applicant formerly operated a solid, infectious, or hazardous facility. • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ Approximate Dates Owned or Operated from (Year) to (Year) _______________________________ Permits or licenses issued pursuant to any environmental protection statute ______________________ Issuing Agency ________________________________________ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ Approximate Dates Owned or Operated from (Year) to (Year) _______________________________ Permits or licenses issued pursuant to any environmental protection statute ______________________ Issuing Agency ________________________________________ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ Approximate Dates Owned or Operated from (Year) to (Year) _______________________________ Permits or licenses issued pursuant to any environmental protection statute ______________________ Issuing Agency ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 6 Your Page No._____ CORPORATE DATA (This section is to be completed only if Applicant is a corporation; otherwise skip to next section.) 2.a. OFFICERS: List the following information as to each officer of the applicant corporation except for any person listed above under the Secondary Business Activity Concern exemption. Submit a Personal History Disclosure Form for each individual named below. • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Office Held ________________________________________ Date Took Office _________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Office Held ________________________________________ Date Took Office _________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Office Held ________________________________________ Date Took Office _________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 7 Your Page No._____ 2.b. DIRECTORS: List the following information as to each director of the Applicant corporation except for any person listed above under the Secondary Business Activity Concern exemption. Submit a Personal History Disclosure Form for each individual named below. • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Date Took Office _________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Date Took Office _________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Date Took Office _________________________ 2.c. EQUITY AND DEBT LIABILITY: Publicly Traded Corporation: If Applicant is a publicly traded corporation, list all individuals or business concerns that directly hold, or are able to control through a subsidiary or holding company, more than five percent equity in or debt liability of the applicant except for any person listed above under the Secondary Business Activity Concern exemption. Privately Held Corporation: If Applicant is a privately held corporation, list all individuals or business concerns that directly hold, or are able to control through a subsidiary or holding company, any equity in or debt liability of the applicant except for any person listed above under the Secondary Business Activity Concern exemption. American LegalNet, Inc. www.FormsWorkFlow.com Page No. 8 Your Page No._____ Submit a Personal History Disclosure Form for all individuals listed below who own or control the Applicant, as defined in O.A.C. 109:6-1-01(S) to wit: “Owns or controls means holds or is able to control the purchase or sale of at least five percent of the equity of a publicly traded corporation or twenty-five percent of the equity of any other business concern, either directly or through a holding company or subsidiary.” Submit a Non-Applicant Business Concern Disclosure Form for all business concerns listed below other than lending institutions required to be licensed or chartered under state or federal law. • Name ________________________________________ Business Address ___________________________________________________________________ Specify Type of Interest (Equity or Debt Liability) and Percent or Amount Held __________________ Percent of Total Equity or Debt Liability Held _____________________________________________ • Name ________________________________________ Business Address ___________________________________________________________________ Specify Type of Interest (Equity or Debt Liability) _________________________________________ Percent of Total Equity or Debt Liability Held _____________________________________________ • Name ________________________________________ Business Address ___________________________________________________________________ Specify Type of Interest (Equity or Debt Liability) _________________________________________ Percent of Total Equity or Debt Liability Held _____________________________________________ 2.d. ARTICLES OF INCORPORATION: Attach a copy of the corporation’s articles. American LegalNet, Inc. www.FormsWorkFlow.com Page No. 9 Your Page No._____ PARTNERSHIP DATA (This section is to be completed only if the Applicant is a partnership; otherwise skip to next section.) 3.a. PARTNERS: List the following information as to each partner of Applicant except for any person listed above under the Secondary Business Activity Concern exemption. If a limited partnership, list limited partners separately with the designation “Limited Partners.” Submit a Personal History Disclosure Form for each individual listed below. • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company _________________________ Federal Employer ID No. (if applicable) __________________________________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company _________________________ Federal Employer ID No. (if applicable) __________________________________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company _________________________ Federal Employer ID No. (if applicable) __________________________________________________ 3.b. FORM OF PARTNERSHIP: Check One. General Partnership ______ Limited Liability Partnership ______ Limited Partnership ______ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 10 Your Page No._____ 3.c. DEBT LIABILITY: Other than the partners listed above, list all individuals or business concerns which hold debt liability of the Applicant except for any person listed above under the Secondary Business Activity Concern exemption. For all individuals listed below, submit a Personal History Disclosure Form. Submit a Non-Applicant Business Concern Disclosure Form for all business concerns listed below other than lending institutions required to be licensed or chartered under state or federal law. • Name ________________________________________ Business Address ___________________________________________________________________ • Name ________________________________________ Business Address ___________________________________________________________________ • Name ________________________________________ Business Address ___________________________________________________________________ 3.d. CERTIFICATE OF PARTNERSHIP: Attach, as applicable, a copy of the certificate of limited partnership, partnership agreement, or agreement of joint venture. OTHER BUSINESS CONCERN DATA (Complete this section only if the Applicant is organized in a form other than a sole proprietorship, corporation, partnership; such as a trust, joint venture, association, or limited liability corporation) 4.a. OFFICERS, DIRECTORS, ETC.: List the following information as to each individual that is an officer or director of the applicant or holds a position that is the equivalent of an officer or director except for any individual listed above under the Secondary Business Activity Concern exemption. Submit a Personal History Disclosure Form for each individual listed below. • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company _________________________ Federal Employer ID No. (if applicable) __________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 11 Your Page No._____ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company _________________________ Federal Employer ID No. (if applicable) __________________________________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company _________________________ Federal Employer ID No. (if applicable) __________________________________________________ 4.b. FORM OF THE BUSINESS CONCERN: Describe how and when the Applicant was organized and under what legal authority it was established. Attach copies of all agreements that describe the establishment of the business concern; for example, a charter. 4.c. EQUITY AND DEBT LIABILITY: List all individuals or business concerns that directly hold, or are able to control through a subsidiary or holding company, any equity in or debt liability of the Applicant except for any person listed above under the Secondary Business Activity Concern exemption. Submit a Personal History Disclosure Form for all individuals listed below who also qualify as persons who own or control the Applicant, as defined in O.A.C. 109:6-1-01(S) to wit: “Owns or controls means holds or is able to control the purchase or sale of at least five percent of the equity of a publicly traded corporation or twenty-five percent of the equity of any other business concern, either directly or through a holding company or subsidiary.” Submit a Non-Applicant Business Concern Disclosure Form for all business concerns listed below other than lending institutions required to be licensed or chartered under state or federal law. • Name ________________________________________ Business Address ___________________________________________________________________ Specify Type of Interest (Equity or Debt Liability)__________________________________________ Percent of Total Equity or Debt Liability Held _____________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 12 Your Page No._____ • Name ________________________________________ Business Address ___________________________________________________________________ Specify Type of Interest (Equity or Debt Liability)__________________________________________ Percent of Total Equity or Debt Liability Held _____________________________________________ • Name ________________________________________ Business Address ___________________________________________________________________ Specify Type of Interest (Equity or Debt Liability)__________________________________________ Percent of Total Equity or Debt Liability Held _____________________________________________ APPLICANT’S FACILITY INFORMATION 5. List below each key employee for the Applicant’s facilities in Ohio and for each key employee listed below submit a Personal History Disclosure Form. If Applicant owns more than one facility in the State of Ohio, attach an additional sheet listing the names and social security numbers of the key employees by facility in the same format as below. Name of Facility: _________________________________________________________ Contact Person: _______________________________________ • Key Employee ________________________________________ Social Security Number ______________________________ • Key Employee ________________________________________ Social Security Number ______________________________ • Key Employee ________________________________________ Social Security Number ______________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 13 Your Page No._____ CORPORATE FAMILY AND SUBSIDIARIES 6.a. ORGANIZATIONAL CHART: If the Applicant is a subsidiary of a parent business concern; or is the parent of one or more subsidiaries, supply a chart showing the names and relationships of all parent, sister, and subsidiary business concerns. Show ultimate parents. 6.b. SOLID, INFECTIOUS, OR HAZARDOUS WASTE SUBSIDIARIES: List the following information as to any business concern, in any state, territory or district of the United States, or in any foreign country, which collects, transports, treats, transfers, stores or disposes of solid, infectious, or hazardous waste on a commercial basis, in which the Applicant holds any equity interest. Submit a Non-Applicant Business Concern Disclosure Form for each business concern listed below. • Name ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Type of Equity ______________________________ Percentage of Total Equity _________________________ • Name ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Type of Equity ______________________________ Percentage of Total Equity _________________________ • Name ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Type of Equity ______________________________ Percentage of Total Equity _________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 14 Your Page No._____ 6.c. OTHER SUBSIDIARIES AND EQUITY INTEREST: List the following information as to any other business concerns in which the Applicant owns or controls more than five percent of the outstanding equity of a publicly traded corporation or more than twenty-five percent of the outstanding equity in any other business concern. • Name ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Type of Equity ______________________________ Percentage of Total Equity _________________________ • Name ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Type of Equity ______________________________ Percentage of Total Equity _________________________ • Name ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Type of Equity ______________________________ Percentage of Total Equity _________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 15 Your Page No._____ LICENSES OR PERMITS HELD 7. OHIO SOLID, INFECTIOUS, OR HAZARDOUS WASTE PERMITS: List any solid, infectious, or hazardous waste permits or licenses ever held by the applicant under any name, or held by any other business concern owned or controlled by the applicant for the operation of a solid, infectious or hazardous waste transportation, storage, transfer or disposal business in Ohio. • Name Under Which Held ________________________________________ Facility Type ________________________________________________________ Facility Location ____________________________________________________________________ Dates Permit or License Held (Year to Year) _________________________________________ Ohio EPA Registration No./U.S. EPA I.D. ________________________________________________ Permit or License Name and Number ___________________________________________________ • Name Under Which Held ________________________________________ Facility Type ________________________________________________________ Facility Location ____________________________________________________________________ Dates Permit or License Held (Year to Year) _________________________________________ Ohio EPA Registration No./U.S. EPA I.D. ________________________________________________ Permit or License Name and Number ___________________________________________________ • Name Under Which Held ________________________________________ Facility Type ________________________________________________________ Facility Location ____________________________________________________________________ Dates Permit or License Held (Year to Year) _________________________________________ Ohio EPA Registration No./U.S. EPA I.D. ________________________________________________ Permit or License Name and Number ___________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 16 Your Page No._____ 8. OUT-OF-STATE SOLID, INFECTIOUS, OR HAZARDOUS WASTE PERMITS: List any past or present permits, registrations, licenses, or equivalent documents held by the Applicant under any name or any other business concern owned or controlled by the Applicant for collection, transportation, treatment, storage, transfer, or disposal of solid, infectious, or hazardous waste in any part of the United States outside of Ohio, or in any foreign country. • Name Under Which Held ________________________________________ Facility Type ________________________________________________________ Facility Location ____________________________________________________________________ Dates Permit or License Held From (Year to Year) ________________________________________ License/Registration No./EPA I.D. ______________________________________________________ • Name Under Which Held ________________________________________ Facility Type ________________________________________________________ Facility Location ____________________________________________________________________ Dates Permit or License Held From (Year to Year) _________________________________________ License/Registration No./EPA I.D. ______________________________________________________ • Name Under Which Held ________________________________________ Facility Type ________________________________________________________ Facility Location ____________________________________________________________________ Dates Permit or License Held From (Year to Year) ________________________________________ License/Registration No./EPA I.D. ______________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 17 Your Page No._____ ADMINSTRATIVE ENFORCEMENT ACTIONS OR PERMIT REVOCATIONS 9. PENDING ADMINISTRATIVE ENFORCEMENT ACTIONS: List and explain any administrative enforcement action (including an administrative order) which (a) is pending against Applicant, (b) may result in the imposition of a sanction, including but not limited to a fine, a penalty, a payment which is made or work or service which is performed in lieu of a fine or penalty, a cessation or suspension of operations; and (c) concerns a violation or alleged violation of a law, rule, or regulation relating to the collection, transportation, treatment, storage, disposal of solid, hazardous, or infectious waste or relating to any environmental statute. If you wish, you may choose to submit an explanation of any of the actions or alleged violations listed below. • Caption of Action ________________________________________ Date Action Commenced or Issued _______________________________ Docket or I.D. No. ____________________________________________ Agency or Tribunal Issuing the Action ___________________________________________________ Description of Violation (Include Dates and Locations) _____________________________________ ___________________________________________________________________________________ Status ____________________________________ Explanation (Optional) _______________________________________________________________ • Caption of Action ________________________________________ Date Action Commenced or Issued _______________________________ Docket or I.D. No. ____________________________________________ Agency or Tribunal Issuing the Action ___________________________________________________ Description of Violation (Include Dates and Locations) _____________________________________ ___________________________________________________________________________________ Status ____________________________________ Explanation (Optional) _______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 18 Your Page No._____ • Caption of Action ________________________________________ Date Action Commenced or Issued _______________________________ Docket or I.D. No. ____________________________________________ Agency or Tribunal Issuing the Action ___________________________________________________ Description of Violation (Include Dates and Locations) _____________________________________ ___________________________________________________________________________________ Status ____________________________________ Explanation (Optional) _______________________________________________________________ 10. RESOLVED ADMINISTRATIVE ENFORCEMENT ACTIONS: List and explain any administrative enforcement action (including an administrative order) in which the Applicant has been involved in the past ten (10) years that (a) has been taken against Applicant, (b) is resolved or dismissed in a settlement agreement or in a consent order or decree or is adjudicated or is otherwise dismissed; (c) resulted in the imposition of a sanction, including but not limited to a fine, a penalty, a payment which is made or work or service which is performed in lieu of a fine or penalty; a cessation or suspension of operations; and (d) concerns a violation or alleged violation of law, rule, or regulation relating to the collection, transportation, treatment, storage, or disposal of solid, hazardous, or infectious waste or relating to any environmental statute. If you wish, you may choose to submit an explanation of any of the actions or alleged violations listed below. • Caption of Action ________________________________________ Docket or I.D. No. ____________________________________________ Agency or Tribunal Issuing the Action ___________________________________________________ Disposition of Action ________________________________________________________________ Description of Violation (Include Dates and Locations) _____________________________________ Explanation of Sanction (Optional) ____________________________________________________ • Caption of Action ________________________________________ Docket or I.D. No. ____________________________________________ Agency or Tribunal Issuing the Action ___________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 19 Your Page No._____ Disposition of Action ________________________________________________________________ Description of Violation (Include Dates and Locations) _____________________________________ Explanation of Sanction (Optional) _____________________________________________________ • Caption of Action ________________________________________ Docket or I.D. No. ____________________________________________ Agency or Tribunal Issuing the Action ___________________________________________________ Disposition of Action ________________________________________________________________ Description of Violation (Include Dates and Locations) _____________________________________ Explanation of Sanction (Optional) _____________________________________________________ 11. ENVIRONMENTAL PERMIT REVOCATIONS: List and explain any revocation, suspension or denial of a license, permit, or equivalent authorization, which was issued to the applicant within the past ten years by any government entity and was issued pursuant to a law, rule, or regulation relating to the collection, transportation, treatment, storage, or disposal of solid, infectious, or hazardous waste or relating to any environmental statute. If you wish, you may choose to submit an explanation of any of the actions or alleged violations, revocations, suspensions or denials listed below. • Caption/Title of Revocation, Suspension or Denial Action ___________________________________ Docket or Other I.D. No. ____________________________________________ Issuing Agency or Tribunal ___________________________________________________ Date of Revocation, Suspension or Denial _______________________________ Explanation of Revocation, Suspension or Denial (optional) __________________________________ • Caption/Title of Revocation, Suspension or Denial Action ___________________________________ Docket or Other I.D. No. ____________________________________________ Issuing Agency or Tribunal ___________________________________________________ Date of Revocation, Suspension or Denial _______________________________ Explanation of Revocation, Suspension or Denial (optional) __________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 20 Your Page No._____ • Caption/Title of Revocation, Suspension or Denial Action ___________________________________ Docket or Other I.D. No. ____________________________________________ Issuing Agency or Tribunal ___________________________________________________ Date of Revocation, Suspension or Denial _______________________________ Explanation of Revocation, Suspension or Denial (optional) __________________________________ CIVIL LITIGATION AND CRIMINAL PROCEEDINGS 12. PENDING CIVIL SUITS: List any civil suit in which the Applicant is currently involved as a defendant to a claim, counterclaim, or cross claim relating to a: a. Violation of a law, rule, or regulation relating to the collection, transportation, treatment, storage, or disposal of solid, hazardous, or infectious waste; or b. Violation of a local ordinance, state, or federal law which relates to environmental protection, unfair competition, fraud or racketeering. If you wish, you may choose to submit an explanation of any of the actions or alleged violations listed below. • Title of Case/Case Caption ___________________________________ Docket No. ____________________________________________ Name and Location of Court ___________________________________________________________ Nature of Suit (Charge) _______________________________________________________________ Date Filed/Initiated __________________________________ Current Status ______________________________________________________________________ Explanation (Optional) _______________________________________________________________ • Title of Case/Case Caption ___________________________________ Docket No. ____________________________________________ Name and Location of Court ___________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 21 Your Page No._____ Nature of Suit (Charge) _______________________________________________________________ Date Filed/Initiated __________________________________ Current Status ______________________________________________________________________ Explanation (Optional) _______________________________________________________________ • Title of Case/Case Caption ___________________________________ Docket No. ____________________________________________ Name and Location of Court ___________________________________________________________ Nature of Suit (Charge) _______________________________________________________________ Date Filed/Initiated __________________________________ Current Status ______________________________________________________________________ Explanation (Optional) _______________________________________________________________ 13. RESOLVED CIVIL SUITS: List any civil suit in which the applicant has ever been involved in the past ten (10) years as a defendant to a claim, counterclaim, or cross claim, and has resulted in a judgment or a consent decree for which applicant was found liable, in whole or in part, for: a. Violation of a law, rule, or regulation relating to the collection, transportation, treatment, storage, or disposal of solid, hazardous, or infectious waste; or b. Violation of local ordinance, state, or federal law which relates to environmental protection, unfair competition, fraud or racketeering. If you wish, you may choose to submit an explanation of any of the actions or alleged violations listed below. • Title of Case/Case Caption ___________________________________ Docket No. ____________________________________________ Name and Location of Court ___________________________________________________________ Nature of Suit or Date of Alleged Violation _______________________________________________ Disposition of the Suit _______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 22 Your Page No._____ Explanation (Optional) _______________________________________________________________ • Title of Case/Case Caption ___________________________________ Docket No. ____________________________________________ Name and Location of Court ___________________________________________________________ Nature of Suit or Date of Alleged Violation _______________________________________________ Disposition of the Suit _______________________________________________________________ Explanation (Optional) _______________________________________________________________ • Title of Case/Case Caption ___________________________________ Docket No. ____________________________________________ Name and Location of Court ___________________________________________________________ Nature of Suit or Date of Alleged Violation _______________________________________________ Disposition of the Suit _______________________________________________________________ Explanation (Optional) _______________________________________________________________ 14. PENDING CRIMINAL CHARGES AND INDICTMENTS: List any criminal prosecution pending against Applicant. If you wish, you may choose to submit an explanation of any of the prosecution listed below. • Crime or Offense Charged ___________________________________ Indictment, Information or Complaint No. ____________________________________________ Date Charged __________________________________ Name and Location of Court Where Charged ______________________________________________ Current Status of Prosecution __________________________________________________________ Explanation (Optional) _______________________________________________________________ • Crime or Offense Charged ___________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 23 Your Page No._____ Indictment, Information or Complaint No. ____________________________________________ Date Charged __________________________________ Name and Location of Court Where Charged ______________________________________________ Current Status of Prosecution __________________________________________________________ Explanation (Optional) _______________________________________________________________ • Crime or Offense Charged ___________________________________ Indictment, Information or Complaint No. ____________________________________________ Date Charged __________________________________ Name and Location of Court Where Charged ______________________________________________ Current Status of Prosecution __________________________________________________________ Explanation (Optional) _______________________________________________________________ 15. CRIMINAL CONVICTIONS: List any criminal conviction rendered against applicant. Include all applicable convictions even if they are arguably not disqualifying. If you wish, you may choose to provide an explanation of the prosecution listed above. See Appendix A for a copy of the disqualifying crimes listed in Ohio Revised Code Section 3734.44(B). • Crime or Offense Pled Guilty To and/or Convicted _________________________________________ Indictment, Information or Complaint No. ____________________________________________ Date Charged __________________________________ Name and Location of Court Where Prosecuted ____________________________________________ Current Status of Prosecution __________________________________________________________ Sentence or Fine Imposed _____________________________________________________________ Explanation (Optional) _______________________________________________________________ • Crime or Offense Pled Guilty To and/or Convicted _________________________________________ Indictment, Information or Complaint No. ____________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page No. 24 Your Page No._____ Date Charged __________________________________ Name and Location of Court Where Prosecuted ____________________________________________ Current Status of Prosecution __________________________________________________________ Sentence or Fine Imposed _____________________________________________________________ Explanation (Optional) _______________________________________________________________ • Crime or Offense Pled Guilty To and/or Convicted _________________________________________ Indictment, Information or Complaint No. ____________________________________________ Date Charged __________________________________ Name and Location of Court Where Prosecuted ____________________________________________ Current Status of Prosecution __________________________________________________________ Sentence or Fine Imposed _____________________________________________________________ Explanation (Optional) _______________________________________________________________ 16. EVIDENCE OF REHABILITATION: If information has been listed in paragraphs 14 or 15 above, set forth any written evidence or arguments you wish to make that demonstrate rehabilitation. Attach additional sheets, if necessary. Attach any additional documents you wish the Director of Ohio EPA and the Attorney General to consider; for example, letters of recommendation. See Appendix B for Rehabilitation Criteria. EXPERIENCE AND CREDENTIALS American LegalNet, Inc. www.FormsWorkFlow.com Page No. 25 Your Page No._____ 17. Describe the Applicant’s experience and credentials in the collection, transportation, treatment, storage or disposal of solid, infectious, or hazardous waste. In addition to those of the Applicant, describe the experience and credentials brought to the business by key employees, officers, directors or partners. You may answer or supplement your response by the inclusion of resumes, lists or professional publications and achievements, and/or cross-references to information included with Annual Update Forms and Personal History Disclosure Forms. American LegalNet, Inc. www.FormsWorkFlow.com Page No. 26 Your Page No._____ AFFIDAVIT STATE OF _________________________: COUNTY OF _________________________: I, _____________________________________, do hereby swear or affirm that the information in this Applicant Disclosure Form is true to the best of my knowledge. I am aware that if any of the foregoing statement made by me is knowingly false, I am subject to criminal prosecution or civil action. If a person other than the individual signing this affidavit (e.g. Accountant or Attorney) prepared this form, indicate that person's name, address and telephone number: Name:________________________________________ Address:___________________________________________________________________ (Number and Street) ___________________________________ _______________________ _______________________ (City) (State) (Zip Code) Telephone:________________________________________ (Area code) – (Telephone Number) Dated this _____ day of ____________________________, 20__. Signature____________________________________ Sworn to and subscribed before me this _____ day of ____________________________, 20__. ____________________________________________ NOTARY PUBLIC My Commission Expires:_______________________ Under Ohio Revised Code 2921.11 and 2929.11, perjury is a felony of the third degree; punishable by imprisonment for one to ten years and a fine up to $5,000. Under Ohio Revised Code 2921.13 and 2929.21, falsification is a misdemeanor of the first degree; punishable by imprisonment for six months and a fine up to $1,000. American LegalNet, Inc. www.FormsWorkFlow.com Page No. 27 Your Page No._____ RELEASE FORM To all Courts, Probation Departments, Selective Service Boards, Credit Bureaus, Employers, Educational Institutions, Banks, Financial and Other Such Institutions, and all Governmental Agencies (federal, state and local without exception both foreign and domestic): On behalf of__________________________________________________ (Applicant) I,________________________________________ (President, Chief Executive, Partner or Sole Proprietor) have authorized the Attorney General of Ohio to conduct an investigation into the background of the said enterprise for the purpose of determining its suitability to hold a solid, infectious, or hazardous waste permit or icense, as provided under Sections 3734.41 - .47 of the Ohio Revised Code. Therefore, you are hereby authorized to release any and all information pertaining to the Applicant, documentary or otherwise, as requested by an appropriate employee, agent or representative of the Attorney General. This authorization shall supersede and countermand any prior request or authorization to the contrary. A copy of this authorization will be considered as effective and valid as the original. _____________________________________ ____________________________ (Signature) (Date) Sworn to and subscribed before me this _____ day of ____________________________, 20__. _____________________________________________ NOTARY PUBLIC My Commission Expires:________________________ Under Ohio Revised Code 2921.11 and 2929.11, perjury is a felony of the third degree; punishable by imprisonment for one to ten years and a fine up to $5,000. Under Ohio Revised Code 2921.13 and 2929.21, falsification is a misdemeanor of the first degree; punishable by imprisonment for six months and a fine up to $1,000. American LegalNet, Inc. www.FormsWorkFlow.com Page No. 28 Your Page No._____ APPENDIX A DISQUALIFYING CRIMES Pursuant to Paragraph (B) of Section 3734.44 of the Ohio Revised Code, an Applicant may be disqualified from holding a solid, infectious, or hazardous waste permit or license if any individual or business concern required to be listed in the disclosure statement, or shown to have a beneficial interest in the business of the Applicant has been convicted of any of 21 categories of crimes listed in the statute. Disqualifying crimes are any of the following under Ohio laws, or equivalent laws of any other jurisdiction: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Murder Kidnapping Gambling Robbery Bribery Extortion Criminal usury Arson Burglary Theft and related crimes Forgery and fraudulent practices Fraud in the offering, sale or purchase of securities Alteration of motor vehicle identification numbers Unlawful manufacture, purchase, use or purchase of firearms Unlawful possession or use of destructive devices or explosives A violation of Revised Code Section 2925.03, 2925.04, 2925.05, 2925.06, 2925.11, 2925.32, or 2925.37 or Chapter 3719, unless the violation is for possession of less than one hundred grams of marihuana, less than five grams of marihuana resin or extraction or preparation of marihuana resin, or less than one gram of marihuana resin in a liquid concentrate, liquid extract, or liquid distillate form Engaging in a pattern of corrupt activity under Revised Code Section 2923.32 Violation of criminal provisions of Chapter 1331 of the Revised Code Any violations of the criminal provisions of any federal or state environmental protection laws, rules, or regulations that is committed knowingly or recklessly as those terms are defined in Section 2901.22 of the Revised Code Violation of Chapter 2909 of the Revised Code Any offense specified in Chapter 2921 of the Revised Code American LegalNet, Inc. www.FormsWorkFlow.com Page No. 29 Your Page No._____ APPENDIX B REHABILITATION CRITERIA Paragraph (C) of Section 3734.44 of the Ohio Revised Code provides for an exception to the disqualification that would otherwise result from a criminal conviction where the Applicant affirmatively demonstrates rehabilitation of the individual or business concern by a preponderance of the evidence. If the convictions are felonies, a permit shall be denied unless, in the case of an individual, five (5) years have elapsed since the individual was fully discharged from imprisonment, probation, and parole for the offense. The Director of the Ohio EPA or the Board of Health is required to request a recommendation from the Attorney General, and to consider the following factors when weighing the issue of rehabilitation: 1. 2. 3. 4. 5. 6. 7. 8. The nature and responsibilities of the position which a convicted individual would hold. The nature and seriousness of the offense. The circumstances under which the offense occurred. The date of the offense. The age of the individual when the offense was committed. Whether the offense was an isolated or repeated incident. Any social conditions which may have contributed to the offense. Any evidence of rehabilitation, including good conduct in prison or in the community, counseling or psychiatric treatment received, acquisition of additional academic or vocational schooling, successful participation in correctional work-release programs, or the recommendation of persons who have or have had the applicant under their supervision. In the instance of an Applicant that is a business concern, rehabilitation shall be established if the Applicant has implemented formal management controls to minimize and prevent the occurrence of violations and activities that will or may result in permit or license denial or revocation or if the Applicant has formalized such controls as a result of a revocation or denial of a permit or license. Such controls may include, without limitation, instituting environmental auditing programs to help ensure the adequacy of internal systems to achieve, maintain, and monitor compliance with applicable environmental laws and standards or instituting an antitrust compliance auditing program to help ensure full compliance with applicable antitrust laws. The business concern shall prove by a preponderance of the evidence that the management controls are effective in preventing the violations that are the subject of concern. American LegalNet, Inc. www.FormsWorkFlow.com