MAIN DISCLOSURE FORM For every applicant for or holder of an Ohio solid, infectious, or hazardous waste permit, and any prospective owner of an off-site facility who is required to file a disclosure statement pursuant to Division (F) of Section 3734.42 of the Ohio Revised Code. Pursuant to O.R.C. 3734.40-3734.47 and O.A.C. Rules 109:6-1-01 through 109:6-1-04 i American LegalNet, Inc. www.FormsWorkflow.com MAIN DISCLOSURE FORM INSTRUCTIONS 1. WHO MUST COMPLETE THIS FORM. Every applicant for or holder of an Ohio solid, infectious, or hazardous waste permit, and any prospective owner of an off-site facility who is required to file a disclosure statement pursuant to Division (F) of Section 3734.42 of the Ohio Revised Code. 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, enter "Not Applicable" or "N/A" in the space provided for an answer. If there is nothing to disclosure 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 answers. If the answer to a question in this form is identical to an answer given to a previous 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 ON DISCLOSURE STATEMENTS MAY RESULT IN THE DENIAL OR REVOCATION OF AN OEPA LICENSE. IN ADDITION, ANY PERSON WHO MAKES FALSE OR MISLEADING STATEMENTS ON THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION. Be especially careful not to leave out 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 you or your company 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, an 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 or the Attorney General, but it will avoid the implication that you are trying to conceal information. ii American LegalNet, Inc. www.FormsWorkflow.com 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 question completely. 4. ADDITIONAL SPACE. If you need additional space to answer a question, use plain 8 1/2 " by 11" paper. Insert additional pages immediately following the page on which the question you are answering appears. Be sure to indicate your answer is "continued on next page," and indicate on the additional page what question is being answered 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. TYPE OR PRINT YOUR ANSWERS. Type or print in legible block letter style. 6. FEES. Certain fees must be paid to Ohio and the Attorney General's Office in connection with the processing of this Disclosure Statement and the investigation of you or your company. O.A.C. Rule 109:6-1-04 describes how these fees are to be calculated. When you have calculated the fees to be submitted, attach your check to the front of this form before submitting it. 7. INTERPRETIVE ASSISTANCE IN COMPLETING DISCLOSURE STATEMENTS. If an applicant, permittee, or prospective owner needs interpretive assistance in completing a disclosure statement, it may submit in writing to the Attorney General a regulatory guidance request seeking an informal, nonbinding 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 rules adopted thereunder. b. There is no obligation upon the Attorney General 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 to 3734.47 of the Ohio Revised Code and the rules adopted thereunder. c. The applicant, permittee, or prospective owner solely as a guidance to assist in the preparation of a disclosure statement shall use the response provided by the Attorney iii American LegalNet, Inc. www.FormsWorkflow.com General to any regulatory guidance request. 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 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. IF YOU HAVE GENERAL NON-INTERPRETIVE QUESTIONS ABOUT HOW TO FILL OUT THIS FORM, CALL THE OFFICE OF THE OHIO ATTORNEY GENERAL (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 3734.40 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 O.A.C. 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 section 3734.43 of the Ohio Revised Code. 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. '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, by 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 the contents of disclosure statements. The Social Security number is used as a secondary identifier by the Ohio Bureau of Criminal Investigation when they conduct background identification, when the Bureau of Criminal Investigation conduct checks of criminal history records maintained by the State and federal governments, and as a cross-check against motor vehicle records. In specific investigations which may involve examination of particular 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 iv American LegalNet, Inc. www.FormsWorkflow.com 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. v American LegalNet, Inc. www.FormsWorkflow.com Page No. 1 Your Page No. _____ MAIN DISCLOSURE FORM This disclosure statement is being filed for the following facility: (Name) (Location) in connection with an: application for a permit for a hazardous waste facility application for a permit for a solid waste facility, other than a solid waste transfer station application for a permit for a solid waste transfer facility existing hazardous waste facility, pursuant to notice from the Attorney General existing solid waste facility, pursuant to notice from the Attorney General change of ownership of the following type of facility: solid waste hazardous waste infectious waste other(describe)___________________________________________ American LegalNet, Inc. www.FormsWorkflow.com Page No. 2 Your Page No. Column for use by Attorney General: Discl. Stmt. submitted 1. Full name, address and phone number of the applicant, permittee, or prospective owner for which this form is submitted. If the named entity is an individual, submit a Personal History Disclosure Form. If the named entity is a business concern, submit a Business Concern Statement. (Full Name) (Phone Number) (Number and Street) (City) 2. (County) (State) (Zip Code) List each individual who is an officer, director, partner, or key employee of a sole proprietorship or business concern listed in Question 1. For each name listed below submit a Personal History Disclosure Form. : : : : : : American LegalNet, Inc. www.FormsWorkflow.com Page No. 3 Your Page No. 3. List each individual who "owns or controls," as that term is defined at O.A.C. Rule 109:6-1-01(R), the business concern listed in Question 1. For each name listed below submit a Personal History Disclosure Form. : : : : : 4. List each business concern, which is a partner of a business concern listed in Question 1. For each name listed below submit a Business Concern (Private or Governmental Entity) Disclosure Form and also a Listed Business Concern Disclosure Form. : : : 5. List each business concern who "owns or controls," as that term is defined at O.A.C. Rule 109:6-1-01(R), the business concern listed in Question 1. For each name listed below submit a Business Concern (Private or Governmental Entity) Disclosure Form and also a Listed Business Concern Disclosure Form. : : American LegalNet, Inc. www.FormsWorkflow.com Page No. 4 Your Page No. ______ 6. List each individual who is an officer, director, or partner of a business concern listed in Question 5. For each name listed below submit a Personal History Disclosure Form. : : : : : : : : : : : : : : : : American LegalNet, Inc. www.FormsWorkflow.com Page No. 5 Your Page No. ___ 7. List each individual who "owns or controls," as that term is defined at O.A.C. Rule 109:6-1-01(R), business concern listed in Question 5. For each name listed below submit a Personal History Disclosure Form. : : : : : : : : : : : : : : : : American LegalNet, Inc. www.FormsWorkflow.com Page No. 6 Your Page No. _____ 8. List each business concern that both (1) is a "subsidiary" of, that, is "owned or controlled" by, an individual or business concern listed in Questions 1, 3, 4, or 5, and (2) has had a: (a) conviction rendered against itself or any if its officers, directors, or the equivalent of a key employees of the subsidiary, for a crime listed in O.R.C. 3734.44(B); or (b) criminal charge filed against itself or any of its officers, directors, or the equivalent of a key employees of the subsidiary, for a crime listed in O.R.C. 3734.44(B); or (c) civil judicial complaint rendered against itself for violation of an environmental protection law resulting in a penalty of fifty thousand dollars or more. (d) judgment of liability rendered against itself for violation of an environmental protection law resulting in a penalty of fifty thousand dollars or more. For each name listed below submit a Subsidiary Disclosure and a Listed Business Concern Disclosure Form. : : : : : : : : American LegalNet, Inc. www.FormsWorkflow.com Page No. 7 Your Page No. _____ 9. List the following information for each business concern in which the applicant, permittee, or prospective owner holds an equity interest and which collects, transfers, transports, treats, stores, or disposes of solid, infectious, or hazardous waste. For each business concern listed below, submit a Listed Business Concern Disclosure Form. Full Name Address Federal Tax I.D. # : : : : : : : : 10. Provide the name of each business concern identified in any Listed Business Concern Disclosure Form. For each business concern identified below, submit a Listed Business Concern Disclosure Form. : : : : : American LegalNet, Inc. www.FormsWorkflow.com Page No. 8 Your Page No. _____ 11. OTHER EMPLOYEES. List the following information as to all employees (other than key employees) employed at the subject facility as of thirty days within filing of the disclosure statement: Name of Employee Home Address Position Date Hired Date of Birth Social Security Number American LegalNet, Inc. www.FormsWorkflow.com Page No. 9 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 Main 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 is true and accurate 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. Date: (Signature) _ (Type or print name here) (Title or position) If a person other than the individual signing this affidavit (e.g., accountant or attorney) prepared the form, indicate that person's name, address and telephone number: Sworn to and subscribed before me this ________________________________ Notary Public day of , 20____. Seal or Authority of 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. 10 Your Page No. _____ RELEASE AUTHORIZATION 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 , 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 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 F:\EBIU\DISCLOSU\MAINDISC.WPD American LegalNet, Inc. www.FormsWorkflow.com