NON-APPLICANT BUSINESS CONCERN DISCLOSURE FORM (PRIVATE AND GOVERNMENT ENTITIES) This form must be completed by Non-Applicant Business Concerns which have a relationship with the Applicant that requires them to file a disclosure statement. Applicant means any person: (1) Seeking a permit, other than a permit modification, or license for an off-site waste facility; (2) Holding a permit or license for an off-site waste facility; or (3) Who is a prospective owner of an off-site waste facility. This form must be completed any Non-Applicant Business Concern that: (1) Directly holds, or are able to control through a subsidiary or holding company, any equity in or debt liability of the Applicant, if the Applicant is a privately held business concern; (2) Directly holds, or are able to control through a subsidiary or holding company, more than five (5) percent equity in or debt liability of the Applicant, if the Applicant is a publicly traded corporation; (3) Is a partner of the Applicant; (4) Is a subsidiary of the Applicant and collects, transfers, transports, treats, stores, or disposes of solid waste, infectious waste, or hazardous waste; (5) Is the operator of an off-site facility for which the Applicant is a government entity; and (6) Is a partner of the operator of an off-site facility for which the Applicant is a government entity and the operator is not an employee of the government entity. Pursuant to O.R.C. 3734.41-3734.47 and O.A.C. Sections 109:6-1-01 through 109:6-1-05 American LegalNet, Inc. www.FormsWorkFlow.com NON-APPLICANT BUSINESS CONCERN DISCLOSURE FORM 1. WHO MUST COMPLETE THIS FORM. Any business concern that: a. Directly holds, or is able to control through a subsidiary or holding company, any equity in or debt liability of an Applicant, if the Applicant is a privately held business concern; ALL business concerns that hold equity in or debt liability of the Applicant must complete this form. This form is not limited to business concerns that own or control the Applicant. b. Directly holds, or is able to control through a subsidiary or holding company, more than per cent equity in or debt liability of the Applicant, if the Applicant is a publicly traded corporation; ALL business concerns that hold more than 5 percent equity in or debt liability of the Applicant must complete this form. This form is not limited to business concerns that own or control the Applicant. c. Is a partner of the Applicant; d. Is a subsidiary of the Applicant and collects, transfers, transports, treats, stores, or disposes of solid waste, infectious waste, or hazardous waste; e. Is the operator of an off-site facility for which the Applicant is a government entity; and f. Is a partner of the operator of an off-site facility for which the Applicant is a government entity and the operator is not an employee of the government entity. As defined by OAC 109:6-1-01(E), “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 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 an 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 American LegalNet, Inc. www.FormsWorkFlow.com 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 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 thereunder. 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 business concern. 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. American LegalNet, Inc. www.FormsWorkFlow.com 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 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 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 federal government agency which requests an individual to disclose his/her 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 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 it conducts background investigations, 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 obtained from outside sources, the Social Security number might 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. Further, a decision not to provide 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 Revised Code Section 3734.41 et seq. American LegalNet, Inc. www.FormsWorkFlow.com Page 1 Your Page ____ NON-APPLICANT BUSINESS CONCERN DISCLOSURE FORM NAME OF THE APPLICANT THIS FORM IS BEING FILED ON BEHALF OF: __________________________________________________________________________________________ RELATIONSHIP OF BUSINESS CONCERN COMPLETING THIS FORM TO THE APPLICANT: _____ Business concern holds equity in or debt liability of the Applicant _____ Business concern is partner of the Applicant _____ Business concern is a subsidiary of the Applicant that collects, transfers, transports, treats, stores, or disposes of solid waste, infectious waste, or hazardous waste; _____ Business concern operates the subject facility on behalf of the Applicant government entity _____ Business concern is a partner of a business concern that operates the subject facility on behalf of the Applicant government entity American LegalNet, Inc. www.FormsWorkFlow.com Page 2 Your Page ____ NON-APPLICANT BUSINESS CONCERN DISCLOSURE FORM NAME OF PERSON TO BE CONTACTED REGARDING THIS FORM: ________________________________________ ________________________________________ (Name) (Title) CONTACT PERSON’S TELEPHONE NUMBER: _______ (Area Code) – (Telephone Number) 1.a. NAME OF THE BUSINESS 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 uses): ____________________________________________________________________________________ TELEPHONE NUMBER: (Area Code) – (Telephone Number) FEDERAL EMPLOYER IDENTIFICATION NUMBER (FEIN):________________________________ SECONDARY BUSINESS ACTIVITY CONCERNS: In each of the past three years, has the business concern 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, business concern qualifies as a Secondary Business Activity Concern. Secondary Business Activity Concerns: List the officers, directors, and any other individuals 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 Form and fingerprinting. • Name ________________________________________ Position Held ________________________________________ • Name ________________________________________ Position Held ________________________________________ • Name ________________________________________ Position Held ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 3 Your Page ____ PAST NAMES OF BUSINESS CONCERN: List all other names under which the business concern has been known or done business in the past ten years and their approximate dates in use. • 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 business concern in the State of Ohio. • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ U.S. EPA Facility I.D. No. ________________________________________ Ohio EPA Registration No. ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 4 Your Page ____ • 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 business concern 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 5 Your Page ____ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ Approximate Dates Owned or Operated from (Year) to (Year) _______________________________ EPA Facility I.D. No. ________________________________________ OEPA 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 business concern 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 6 Your Page ____ 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 business concern formerly operated a solid, infectious, or hazardous facility. • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ From (Year) to (Year) __________________________________________ Permits issued pursuant to any environmental protection statute ______________________________ Issuing Agency ________________________________________ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ From (Year) to (Year) __________________________________________ Permits issued pursuant to any environmental protection statute ______________________________ Issuing Agency ________________________________________ • Name ________________________________________ Address ___________________________________________________________________________ Facility Type ________________________________________ From (Year) to (Year) __________________________________________ Permits issued pursuant to any environmental protection statute ______________________________ Issuing Agency ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 7 Your Page ____ CORPORATE DATA (This section is to be completed only if the business concern is a corporation; otherwise skip to next section.) 2.a. OFFICERS: List the following information as to each officer of the corporation except for any person listed above under the Secondary Business Activity Concern exemption. Submit a Personal History Disclosure Form for all individuals listed below if the business concern completing this form owns or controls 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 per cent 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.” • 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 8 Your Page ____ 2.b. DIRECTORS: List the following information as to each director of the corporation except for any individual listed above under the Secondary Business Activity Concern exemption. Submit a Personal History Disclosure Form for all individuals listed below if the business concern completing this form owns or controls 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 per cent 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.” • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ 2.c. ARTICLES OF INCORPORATION: Attach a copy of the articles of incorporation. PARTNERSHIP DATA (This section is to be completed only if the business concern is a partnership; otherwise skip to next section.) 3.a. PARTNERS: List the following information as to each partner 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 if the business concern completing this form owns or controls the applicant, as defined in O.A.C. 109:6-1-01(S). • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 9 Your Page ____ 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 ______ 3.c. Attach, as applicable, a copy of the certificate of limited partnership or partnership agreement. American LegalNet, Inc. www.FormsWorkFlow.com Page 10 Your Page ____ OTHER BUSINESS CONCERN DATA (Complete this section only if the business concern is organized in a form other than a sole proprietorship, corporation, or partnership; such as a trust, association, joint venture, or LLC.) 4.a. OFFICERS, DIRECTORS, ETC.: List the following information as to each individual that is an officer or director of the business concern 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 all individuals listed below if the business concern completing this form owns or controls 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 per cent 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.” • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company ______________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Company ______________________________ • Name ________________________________________ Social Security Number ______________________________ Date of Birth _________________________ Position in Company ______________________________ 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. American LegalNet, Inc. www.FormsWorkFlow.com Page 11 Your Page ____ SUBSIDIARIES 5. SOLID, INFECTIOUS, OR HAZARDOUS WASTE SUBSIDIARIES: List the following information for any subsidiary that collects, transports, treats, transfers, stores, or disposes of solid, infectious, or hazardous waste and in which the non-applicant business concern holds a more than five percent equity interest. • Name of Business Concern ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Percentage of Equity Held by Non-Applicant Business Concern _________________________ • Name of Business Concern ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Percentage of Equity Held by Non-Applicant Business Concern _________________________ • Name of Business Concern ________________________________________ Business Address & Telephone ________________________________________________________ Federal Employer ID Number _________________________ Percentage of Equity Held by Non-Applicant Business Concern _________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 12 Your Page ____ LICENSES OR PERMITS HELD 6. SOLID, INFECTIOUS, OR HAZARDOUS WASTE PERMITS: List any permits, licenses, or equivalent documents, past or present, held by the business concern 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 Location ____________________________________________________________________ Type of Issuing License Agency ________________________________________________________ Dates Permit of License Held From (Year to Year) _________________________________________ License/Registration No./EPA I.D. ______________________________________________________ • Name Under Which Held ________________________________________ Facility Location ____________________________________________________________________ Type of Issuing License Agency ________________________________________________________ Dates Permit or License Held From (Year to Year) _________________________________________ License/Registration No./EPA I.D. ______________________________________________________ • Name Under Which Held ________________________________________ Facility Location ____________________________________________________________________ Type of Issuing License Agency ________________________________________________________ Dates Permit or License Held From (Year to Year) _________________________________________ License/Registration No./EPA I.D. ______________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com Page 13 Your Page ____ CIVIL VIOLATIONS HISTORY 7. PENDING ADMINISTRATIVE ENFORCEMENT ACTIONS: List and explain any administrative enforcement action (including an administrative order) which (a) is pending against the business concern, (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 14 Your Page ____ • 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) _______________________________________________________________ 8. ENVIRONMENTAL PERMIT REVOCATIONS: List and explain any revocation, suspension or denial of a license, permit, or equivalent authorization, which was issued to the business concern 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 above. • 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 15 Your Page ___ • 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) __________________________________ 9. EVIDENCE OF REHABILITATION: Set forth any written evidence or arguments you wish to make that demonstrate rehabilitation related to circumstances where the business concern has been adjudged liable or a consent decree has been entered in an administrative enforcement action, civil suit, or criminal prosecution against the business concern. See Appendix A for a copy of the disqualifying crimes listed in Ohio Revised Code 3734.44(B). 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 10. 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 Disclosure Affidavits and Personal History Disclosure Forms. American LegalNet, Inc. www.FormsWorkFlow.com Page 16 Your Page ____ AFFIDAVIT STATE OF _________________________: COUNTY OF _________________________: I, _____________________________________, do hereby swear or affirm that the information in this NonApplicant Business Concern 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) 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 17 Your Page ____ 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__________________________________________________ (Non-Applicant Business Concern) 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 3734.41 - .47 of the Ohio Revised Code. Therefore, you are hereby authorized to release any and all information pertaining to the Non-Applicant Business Concern, 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 18 Your Page ____ 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 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 19 Your Page ____ 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