BUSINESS CONCERN DISCLOSURE FORM (PRIVATE AND GOVERNMENT ENTITIES) For each business concern which is an applicant for or holder of a solid waste, or infectious waste, or hazardous waste permit, and prospective owners of an off-site facility and for each business concern which is a partner of such applicant, or permittee, or prospective owner, and for each business concern which owns or controls the applicant, permittee, or prospective owner. Also, for a government entity which is the applicant, permittee, or prospective owner of the subject facility, that government entity must answer Questions 11 through 16 and Question 21 on this form. The government entity should also complete the questions on pages 1 and 2 located prior to Question 1, of this form. Pursuant to R.C. 3734.40-3734.47 and O.A.C. Sections 109:6-1-01 through 109:6-1-05 American LegalNet, Inc. www.FormsWorkflow.com BUSINESS CONCERN DISCLOSURE FORM 1. WHO MUST COMPLETE THIS FORM. Each business concern which is an applicant for, or holder of, a solid waste infectious waste, or hazardous waste permit, and prospective owners of an off-site facility and for each business concern which is a partner of such applicant, or permittee, or prospective owner, and for each business concern which owns or controls such applicant, permittee, or prospective owner, must complete this forms. Sole proprietors must complete this form and an Annual Maintenance Update/New Call-In/Personal History Disclosure Form. Also, a government entity, which is the applicant, permittee, or prospective owner of the subject facility, must answer Questions 11 through 16 and Question 21 on this form. 2. ALL QUESTIONS MUST BE ANSWERED. Read every question carefully before answering any. 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”. WARNING: FRAUDULENT, DECEPTIVE OR MISLEADING ANSWERS MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE. IN ADDITION, ANY PERSON WHO KNOWINGLY OR RECKLESSLY MAKES FALSE OR MISLEADING STATEMENTS ON THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION. Be especially careful not to omit information in a way that might create an impression that you are trying to hide it. For example, a minor criminal conviction will probably not disqualify your firm from being licensed – but attempting to conceal the conviction may lead to a finding of untrustworthiness, and result in disqualification. Omitting such information from this form, even unintentionally, may result in your trustworthiness being questioned. Even if the question is resolved in your favor, your application may be delayed while the inquiry goes forward. 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 OEPA 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 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. 7. INTERPRETIVE ASSISTANCE IN COMPLETING DISCLOSURE STATEMENTS. If an applicant, permittee, or prospective owner needs 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 3734.40 to 3734.47 of the Ohio Revised Code and the rules adopted thereunder. a. The submission of a regulatory guidance request shall in no way alter the obligation of an applicant, permittee or prospective owner to fully comply with all requirements imposed by sections 3734.40 to 3734.47 of the Ohio Revised Code and the Ohio Administrative Rules adopted thereunder. b. The Attorney General is under no obligation to respond to a regulatory guidance request other than as the Attorney General determines in his or her sole discretion, based upon available human resources and the need to employ those resources to perform the mandatory obligations imposed by Sections 3734.40 of the Ohio Revised Code and the rules adopted thereunder. c. The response provided by the Attorney General to any regulatory guidance request shall be used by the applicant, permittee, or prospective owner solely as a guidance to assist in the preparation of a disclosure statement. The response of the Attorney General shall not be binding upon anyone, including, but not limited to, the applicant, permittee or prospective owner, the Attorney General, the Director of the Environmental Protection Agency, a local board of health, or the Hazardous Waste Facility Board. The response may be accorded such deference as is usually provided to the administrative interpretation of a statutory requirement. American LegalNet, Inc. www.FormsWorkflow.com IF YOU HAVE GENERAL NON-INTERPRETIVE QUESTIONS ABOUT HOW TO FILL OUT THIS FORM, CALL THE ATTORNEY GENERAL’S OFFICE AT (614) 466-3843. 8. The information required to be submitted in the disclosure statement pursuant to O.A.C. Rule 109:6-1-02 is intended to be the information necessary to begin the background investigation required by Sections 3743.40 through 3734.47 of the Ohio Revised Code. 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 believe that the procedures contained in section 3734.43 of the Ohio Revised Code should be employed to review additional information. Nothing contained in rule 109:6-1-02 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. 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 government agency which requests an individual to disclose his Social Security account number, must inform that individual whether the disclosure is mandatory or voluntary, but what statutory or other authority such number is solicited, and what uses will be made of it. 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. Under Section 7(a) of the Privacy Act, the State of Ohio cannot 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 3734.40 et seq. American LegalNet, Inc. www.FormsWorkflow.com Page No. 1 Your Page No. BUSINESS CONCERN DISCLOSURE FORM NAME OF APPLICANT, PERMITTEE, OR PROSEPCTIVE OWNER: RELATIONSHIP OF BUSINESS CONCERN COMPLETING THIS FORM WITH THE APPLICANT, PERMITTEE, OR PROSPECTIVE OWNER: Business concern is the applicant, permittee, or prospective owner. Business concern is partner of the applicant, permittee, or prospective owner. Business concern owns or controls the applicant, permittee, or prospective owner. Business concern is the operator of the subject facility for which the applicant, permittee, or prospective owner is a government entity. Business concern is a partner of the operator of the subject facility for whic h the applicant, permittee, or prospective owner is a government entity and the operator is not an employee of the government entity. Government entity is the applicant, permittee, or prospective owner of the subject facility, and therefore must answer Questions 11 through 16 and Question 21 on this form. American LegalNet, Inc. www.FormsWorkflow.com Page No. 2 Your Page No. BUSINESS CONCERN DISCLOSURE FORM NAME OF PERSON TO BE CONTACTED IN REGARDING THESE FORMS: (Name) (Title) CONTACT PERSON’S TELEPHONE NUMBER: (Area Code) 1.a. NAME OF BUSINESS THE CONCERN COMPLETING THIS FORM. State the complete name of the business concern as it appears on the certificate of incorporation, charter, by-laws, partnership agreement or other official document which establishes the name of the business concern. (If no such document exists, state the name the business ses.): TELEPHONE NUMBER: FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN): PAST NAMES OF BUSINESS CONCERN. List all other names under which the business concern has been known or done business in the past twenty years. Name Approximate Dates Name Was in Use From (Year) To (Year) American LegalNet, Inc. www.FormsWorkflow.com Page No. 3 Your Page No. 1.b. TYPE OF BUSINESS CONCERN. Check one: Sole Proprietorship Trust Partnership Joint Venture Limited Partnership Other (Describe)_____________ DATE AND PLACE OR ORGANIZATION. State when and where the business concern was established (date of incorporation, partnership agreement, filing of fictitious name certificate, etc.). 1.c. STREET ADDRESS OF PRINCIPAL OFFICE: (Number and Street) (City) 1.d. (State) (Zip Code) MAILING ADDRESS, IF DIFFERENT: (Number and Street) City) 1.e. (State) (Zip Code) STREET ADDRESS OF OTHER OFFICE: (Number and Street) (City) (State) (Zip Code) American LegalNet, Inc. www.FormsWorkflow.com Page No. 4 Your Page No. 1.f. MAILING ADDRESS OF OTHER OFFICES, IF DIFFERENT: (Number and Street) City) 1.g. (State) PAST ADDRESSES OF PRINCIPAL OFFICE. List all addresses of past locations of the business concern’s principal office for the past twenty years. Name 1.h. (Zip Code) Approximate Dates Used as Principal Office From (Year) To (Year) FACILITIES IN OHIO. List all solid, hazardous, or infectious waste facilities of the business concern in the State of Ohio. Address Type of Facility EPA Facilities I.D. No. & OEPA Registration No. American LegalNet, Inc. www.FormsWorkflow.com Page No. 5 Your Page No. 1.i. FORMER FACILITIES IN OHIO. List all solid, hazardous, or infectious waste facilities formerly owned and/or operated by the business concern in the State of Ohio. Address 1.j. Address EPA Facility I.D. No. & OEPA Registration # 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 business concern is currently operating a solid, infectious, or hazardous facility. Address & Telephone No. 1.k. Approximate Dates in Use From (Year) To (Year) Type of Facility Type of Facility EPA Facility I.D. No. (if any) 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 business concern formerly operated a solid, infectious, or hazardous facility. Type of Facility From (Year) To (Year ) Permits (Issued pursuant to Any environmental protection Statue.) Give Name & Issuing Agency American LegalNet, Inc. www.FormsWorkflow.com Page No. 6 Your Page No. CORPORATE BUSINESS CONCERN DATA (This section to be completed only by corporations). 2.a. STATUTORY AGENT. State the name and address of the Ohio Registered Statutory Agent for service of process. Name 2.b. Address CORPORATE ACCOUNTANT. State the name, address and telephone number(s) of the corporation’s accountant, if any. Name 2.c. Name Telephone Number DATE AND PLACE OF INCORPORATION. If incorporated outside Ohio, state the date on which the corporation received a license to do business in Ohio, as per Section 1703.03 of the Ohio Revised Code. Name 2.d. Address Place (State,etc.) Date Received License to do Business OFFICERS. List the following information as to each officer of the corporation. Place (State,etc.) Office Held Date took Office Date of Birth Social Security No. American LegalNet, Inc. www.FormsWorkflow.com Page No. 7 Your Page No. 2.e. Name 2.f. DIRECTORS. List the following information as to each director of the corporation. Business Address & Telephone No. Date of Birth Date took Office FORMER OFFICERS AND DIRECTORS. List the following information as to each person who was an officer or director of the corporation at any time during the last 10 years and is not listed in the responses above. Date Held Office Name 2.g. Social Security No. Last Known Address Position Held From To Date of Birth Social Security No. Attach a copy of the articles of incorporation. American LegalNet, Inc. www.FormsWorkflow.com Page No. 8 Your Page No. PARTNERSHIP/JOINT VENTURE DATA (This section to be completed only by partnerships or joint ventures.) 3.a PARTNERS. List the following information as to each partner or joint venturer. If a limited partnership, list limited partners separately under the heading “Limited Partners.” Name 3.b. Business Address & Telephone No. Position in Company Date of Birth (Individual) FORM OF PARTNERSHIP. Check One. General Partnership Limited Partnership Joint Venture 3.c. STATUTORY AGENT and ACCOUNTANT. State the name, address and telephone number(s) of the partnership’s statutory agent and accountant, if any. If the business concern is limited partnership, list the name, address and telephone number of the statutory agent. 3.d. Attach as applicable, a copy of the certificate of limited partnership, partnership agreement, or agreement of joint venture. American LegalNet, Inc. www.FormsWorkflow.com Page No. 9 Your Page No. OTHER BUSINESS CONCERN DATA (Complete this section only if the business concern is organized in a form other than a sole proprietorship, corporation, partnership or joint venture – such as a trust or association.) 4.a. OWNERS, OFFICERS, etc. List the following information as to each person that owns, controls or is an officer of the business concern. Name Business Address & Telephone No. Company Date of Birth FEIN No. 4.b. FORM OF THE BUSINESS CONCERN. Describe how and when the business concern 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. ACCOUNTANT and STATUTORY AGENT. State the name, address and telephone number(s) of the business concern’s accountant and statutory agent, if any. Name Address Telephone No.(s) American LegalNet, Inc. www.FormsWorkflow.com Page No. 10 Your Page No. SUBSIDIARIES AND STOCK HOLDINGS 5. SOLID, INFECTIOUS, OR HAZARDOUS WASTE SUBSIDIARIES AND AFFILIATES. 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 business concern holds more than a five percent (5%) interest of the outstanding equity. Name of Total Business Concern 6. Business Address & Telephone No. Federal Employer ID Number Type of Equity % of Total Equity OTHER SUBSIDIARIES AND EQUITY INTEREST. List the following information as to any business concerns in which the applicant or permittee owns or controls more than 5% of the outstanding equity of a publicly traded corporation or more than 25% of any other business concern. Name of Total Business Concern Business Address & Telephone No. Federal Employer ID Number Type of Equity % of Total Equity American LegalNet, Inc. www.FormsWorkflow.com Page No. 11 Your Page No. 7. CORPORATE FAMILY. If the applicant or permittee is a subsidiary of a parent corporation; or is the parent of one or more subsidiaries, or is part of a conglomerate, supply a chart showing the names and relationships of all parent, sister, subsidiary and affiliate corporations, and/or members of the conglomerate. Show ultimate parents. If the business concern is privately held, or is a publicly traded corporation with more than 25% of its stock held by relatives, show on the chart all other business concerns owned or controlled by relatives, to the extent that the applicant or permittee knows or can reasonably ascertain ownership or control by relatives. (Note: This question applies to related companies in any business, not just the solid, infectious, or hazardous waste businesses.) 8.a. EQUITY – PUBLICLY TRADED CORPORATIONS. If the business concern is a publicly traded corporation: Indicate below how the corporation’s stock is traded. NYSE Over-the-Counter AMEX Listing Symbol Other Exchanges 8.b. Attach or enclose a copy of the corporation’s most recent annual report to stockholders and most recent SEC Form 10-K. 9. FINANCIAL INSTITUTIONS AND FINANCIAL HISTORY. If the business concern has had any petition under any provisions of the Federal Bankruptcy Act or any state insolvency law filed by or against it in the past ten years, list all such actions below. Attach a copy of any final discharge or confirmation of plans on the bankruptcy petition. Title of Action Court and Location Nature of Action Date of Petition Current Status or Disposition American LegalNet, Inc. www.FormsWorkflow.com Page No. 12 Your Page No. 10. If any receiver, fiscal agent, trustee, reorganization trustee or similar officer for the business or property of the business concern has been appointed by a court within the past ten years, list the following information: Name Business & Telephone Number Date Appointed Acted Until (Date) Appointing Court Current Status or Disposition LICENSES AND PERMITS HELD 11. SOLID, INFECTIOUS, OR HAZARDOUS WASTE PERMITS. List any solid, infectious, or hazardous waste permits or licenses or equivalent documents ever held by the business concern under any name, or any other business concern owned or controlled by the applicant or permittee or prospective owner for the operation of a solid, infectious or hazardous waste transportation, storage, transfer or disposal business in Ohio. Name Under Which Held Facility Location Type of Facility Dates License Held From (Year to Year) OEPA Registration No./EPA I.D. American LegalNet, Inc. www.FormsWorkflow.com Page No. 13 Your Page No. 12. OUT-OF-STATE SOLID, INFECTIOUS, OR HAZARDOUS WASTE PERMITS. List any permits, past or present, held by the business concern under any name or any other business concern owned or controlled by the applicant or permittee or prospective owner 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. “Permit” includes registration, license, or equivalent. Name Under Which Held Facility Location or Business Address Type of Issuing License Agency Dates License Held From - To License/ Registration No./ EPA I.D. CIVIL VIOLATIONS HISTORY 13. PENDING ADMINISTRATIVE ENFORCEMENT ACTIONS. List and explain any administrative enforcement action (including an administrative order or notice of violation) which (a) is pending against you or a business concern owned or controlled by you, (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. Caption of Action Date Action Commenced or Issued Docket or I.D. No Agency or Tribunal Issuing the Action Description of Violation (Incl.Dates & Location) Status Explanation (Optional) American LegalNet, Inc. www.FormsWorkflow.com Page No. 14 Your Page No. 14. OTHER ADMINISTRATIVE ENFORCEMENT ACTIONS. List and explain any administrative enforcement action (including an administrative order or notice of violation) which (a) is taken against you or a business concern owned or controlled by you, (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. Caption of Action Docket or I.D. No Tribunal Issuing the Action Disposition Of Action Violation (Incl. Dates & Location Imposed) Sanction Explanation (Optional) American LegalNet, Inc. www.FormsWorkflow.com Page No. 15 Your Page No. 15. ENVIRONMENTAL PERMIT REVOCATIONS. List and explain any revocation, suspension or denial of a license, permit, or equivalent authorization, which revocation was issued 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. Caption / Title of Revocation, Suspension or Denial Action (Optional) Docket or Other I.D. No Issuing Agency or Tribunal Date of Revocation Suspension or Denial Reason for Revocation Suspension or Denial Provide any explanation of the action, alleged violation, revocation, suspension or denial. (Identify which action by Caption/Title and Docket/Identification Number.) American LegalNet, Inc. www.FormsWorkflow.com Page No. 16 Your Page No. CIVIL LITIGATION AND CRIMINAL PROCEEDINGS 16. PENDING CIVIL SUITS. Are you involved in any civil suit which is pending, where you or a business concern, which you owned or controlled, is a defendant to a claim, counterclaim, or cross claim, and may result in liability or imposition of a sanction, in whole or in part, against you or a business concern you owned or controlled and is brought under a 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 “yes”, provide the following information: Title of Case / Case Caption Docket Number Name & Location of Court Nature of Suit (Charge) Date Filed / Initiated Current Status Provide any explanation of the action or alleged violation, which you may choose to submit. (Identify which action by Caption/Title and Docket Number.) American LegalNet, Inc. www.FormsWorkflow.com Page No. 17 Your Page No. 17. CIVIL SUITS. Have you ever been involved in any civil suit where you or a business concern which you owned or controlled was a defendant to a claim, counterclaim, or cross claim, has resulted in a judgment or consent decree or consent order; and resulted in liability or imposition of a sanction, in whole or in part, against you or a business concern you owned or controlled and was brought under a local ordinance which relates to environmental protection, unfair competition, fraud or racketeering, or a state, or federal law, or which alleged a common law claim of fraud, misrepresentation, breach or interference with contract or a reckless or intentional tort? If “Yes”, provide the following information: Title of Case / Case Caption Docket Number Name & Location of Court Nature of Suit or Date of Alleged Violation Disposition of the Suit Provide any explanation of the action or alleged violation, which you may choose to submit. (Identify which action by Caption/Title and Docket Number) American LegalNet, Inc. www.FormsWorkflow.com Page No. 18 Your Page No. 18. PENDING CRIMINAL CHARGES AND INDICTMENTS. For any criminal prosecution pending against you or a business concern which you owned or controlled during the time of the alleged crime, state or provide: Crime or Offense Charged Indictment, Information or Complaint No. Date Charged Name and Location of Court Where Charged Current Status of Prosecution (Note) List all applicable charges or indictments – even if they are arguably not disqualifying. Provide any explanation of the prosecution you may choose to submit. (Identify prosecution by indictment number.) 19. CRIMINAL CONVICTIONS. For any criminal conviction against you or controlled during the time of the alleged crime, state or provide: Crime or Offense Pled Guilty to and/ or Convicted Indictment, Information, or Complaint No. Date Charged Name & Location of Court Where Prosecuted Current Status of Prosecution Sentence or Fine Imposed (Note) List all applicable convictions – even if they are arguably not disqualifying. Provide any explanation of the prosecution you may choose to submit. (Identify prosecution by indictment number.) American LegalNet, Inc. www.FormsWorkflow.com Page No. 19 Your Page No. 20. SEALED RECORDS OF CONVICTION. If you or a business concern you owned or controlled during the time of the alleged crime, were convicted of a crime enumerated in Paragraph (B) of 3734.44 of the Ohio Revised Code, and also set forth in Appendix A, and you or the business concern obtained a sealed record of the conviction in accordance with Paragraph (B) of 2953.33 of the Ohio Revised Code, state of provide: Crime or Offense Plead Guilty to and/or Convicted Indictment, Information, or Complaint No. Date Charged Name & Location of Court Where Prosecuted Current Status of Prosecution Sentence or Fine Imposed (Note) List all applicable convictions – even if they are arguably not disqualifying. Provide any explanation of the prosecution you may choose to submit. (Identify prosecution by indictment number.) A conviction for any of the crimes listed in Appendix A, may result in any business concern with which you are associated having its solid or hazardous waste license denied or revoked, unless you can demonstrate rehabilitation, “by a preponderance of the evidence,” to the Ohio Environmental Protection Agency and the Attorney General. In determining whether rehabilitation has been demonstrated, OEPA will request a recommendation from the Attorney General. Some of the factors OEPA will consider are set forth in Appendix A. If OEPA makes an initial determination that rehabilitation has not been demonstrated, you will have an opportunity to supplement the record, either informally or in a hearing before an Administrative Law Judge, or both, before the Director’s decision becomes final. Under Section 3734.46 of the Ohio Revised Code, an applicant or licensee has the option of avoiding disqualification by severing the employment or interest of the person who would otherwise cause disqualification. DISLOSING A CRIMINAL CONVICTION MAY RESULT IN YOUR EMPLOYER DISMISSING YOU. HOWEVER, YOU CANNOT FAIL TO DISCLOSE THE CONVICTION. If you lie on this form you can be criminally prosecute. American LegalNet, Inc. www.FormsWorkflow.com Page No. 20 Your Page No. IF YOU HAVE BEEN CONVICTED OR ACCUSED OF ANY OF THE CRIMES LISTED IN APPENDIX A, IT IS STRONGLY SUGGESTED YOU DISCUSS YOUR LEGAL RIGHTS WITH AN ATTORNEY, ESPECIALLY IF YOUR EMPLOYER IS NOT AWARE OF YOUR CRIMINAL RECORD. 21. EVIDENCE OF REHABILITATION. 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 OEPA and the Attorney General to consider; for example, letters of recommendation. EXPERIENCE AND CREDENTIALS 22. Describe the business concern’s experience and credentials in the collection, transportation, treatment, storage or disposal of solid, infectious, or hazardous waste. In addition to those of the business concern, 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 Maintenance Update/New Call-In/ Personal History Disclosure Forms. American LegalNet, Inc. www.FormsWorkflow.com Page No. 21 Your Page No. AFFIDAVIT STATE OF ) ) ) COUNTY OF I, , do hereby swear (or affirm) that I am authorized and able to supply the information in this Business Concern Disclosure Form and that such information about the business concern given in answer to Questions (Please circle the Questions to which this affidavit applies). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 is true and accurate to the best of my knowledge. I am aware that if any of the foregoing statements made by me are knowingly false, I am subject to criminal prosecution or civil action. Dated: (Signature) (Type or Print Name Here) (Title or Position) If the form was prepared by a person other than the individual signing this affidavit (e.g., accountant or attorney), indicate that person’s name, address and telephone number: Sworn to and subscribed before me this day of ,20 Seal or authority of Notary Public Notary Public *Sufficient affidavits should be attached such that some person swears to the truth and accuracy of the information of the answers to each question in this form. American LegalNet, Inc. www.FormsWorkflow.com Page No. 22 Your Page No. APPENDIX A DISQUALIFYING CRIMES Pursuant to Paragraph (B) of Section 3734.44 of the Ohio Revised Code, and applicant or licensee 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 or the permittee, 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 securities; Unlawful possession or use of destructive devices or explosives; Violation of Sections 2925.03, 2925.11,2925.32 or 2925.37 or Chapter 3719 of the Ohio Revised Code, except possession of less than one hundred grams of marijuana, or unless the amount of marijuana resin, or extraction or preparation of such resin is less than five grams, and the amount of such resin in a liquid concentrate, liquid extract, or liquid distillate form is less than one gram; Corrupt activities under Sections 2923.31 to 2923.36 of the Ohio Revised Code; Violation of criminal provisions of Chapter 1331 of the Ohio 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 Ohio Revised Code; Violation of Chapter 2909 of the Ohio Revised Code; Any offense specified in chapter 2921 of the Ohio Revised Code. American LegalNet, Inc. www.FormsWorkflow.com Page No. 23 Your Page No. APPENDIX A 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 felony 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 years have elapsed since the individual was fully discharged from imprisonment, probation, and parole for the offense. The Director, Hazardous Waste Facility Board 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 violation 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 system to achieve, maintain, and monitor compliance with applicable environmental laws and standards or instituting and 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 Page No. 24 Your Page No. GENERAL RELEASE AUTHORIZATION To All Courts, Probation Departments, Selective Services Boards, Credit Bureaus, Employers, Educational Institutions, Banks, Financial and other such Institutions, and all Governmental Agencies – federal, state and local with out exception both foreign and domestic. On behalf of 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 license, as provided under Sections 3734.40 - .47 of the Ohio Revised Code. Therefore, you are hereby authorized to release any and all information pertaining to the said enterprise, 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 photostatic copy of this authorization will be considered as effective and valid as the original. (Signature) Sworn to and subscribed before me on this day of 20 . Seal or authority of Notary Public Notary Public American LegalNet, Inc. www.FormsWorkflow.com