Applicant Disclosure Form

APPLICANT DISCLOSURE FORM This form must be completed by every Applicant: (1) Seeking an Ohio solid, infectious, or hazardous waste permit, other than a permit modification, or license for an off-site facility; (2) Holding a solid, infectious, or hazardous waste permit or license for an off-site facility; or (3) Who is a prospective owner of an off-site facility. Pursuant to Ohio Revised Code 3734.41 through 3734.47 and Ohio Administrative Code 109:6-1-01 through 109:6-1-05 American LegalNet, Inc. www.FormsWorkFlow.com APPLICANT DISCLOSURE FORM 1. WHO MUST COMPLETE THIS FORM. Any individual, business concern, or governmental entity who qualifies as an applicant under O.A.C. 109:6-1-01(B). As defined by O.A.C. 109:6-1-01, "Applicant" means any person: (1) (2) (3) Seeking a permit, other than a permit modification, or license for an off-site facility; Holding a permit or license for an off-site facility; or A prospective owner of an off-site facility. As defined by O.A.C. 109:6-1-01, "Business concern" means any corporation, association, firm, partnership, trust, sole proprietorship, or other form of commercial organization. 2. ALL QUESTIONS MUST BE ANSWERED. Read every question carefully before you begin answering any question. Answer every question completely. Do not leave any blank spaces. If a question does not apply to you, enter "Not applicable" or "N/A" in the space provided for an answer. If there is nothing to disclose in answer to a particular question, enter "None" in the space provided for an answer. 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". 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. 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. 3. 4. 6. American LegalNet, Inc. www.FormsWorkFlow.com 7. INTERPRETIVE ASSISTANCE IN COMPLETING DISCLOSURE STATEMENTS. If you need interpretive assistance in completing a disclosure statement, you may submit in writing to the Attorney General a regulatory guidance request seeking an informal, non-binding interpretation of a regulatory requirement imposed by Sections 3734.41 to 3734.47 of the Ohio Revised Code and the rules adopted there under. The information required to be submitted in the disclosure statement is intended to be the information necessary to begin the background investigation required by Sections 3743.41 through 3734.47 of the Ohio Revised Code. By signing the Release Form below you agree to allow the Attorney General to check your background for administrative, civil, and criminal violations, your credit history, and report this information to the Ohio EPA. In limiting the scope of information required to be included in the disclosure statement, it is expressly contemplated that in individual investigations, the Attorney General may have reasonable cause to engage in additional review of the Applicant. Nothing contained herein shall be construed to restrict or limit the scope of the information the Attorney General may seek pursuant to the procedures established in Sections 3734.43 of the Ohio Revised Code. 8. IF YOU HAVE GENERAL QUESTIONS ABOUT HOW TO FILL OUT THIS FORM, CALL THE ATTORNEY GENERAL'S OFFICE AT (614) 466-3843. WARNING: FRAUDULENT, DECEPTIVE OR MISLEADING ANSWERS MAY RESULT IN THE DENIAL OR REVOCATION OF YOUR LICENSE OR PERMIT. IN ADDITION, ANY PERSON WHO KNOWINGLY OR RECKLESSLY MAKES FALSE OR MISLEADING STATEMENTS ON THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION. If you are unsure of, or do not remember the answer to a question, indicate this in some way ­ for example, by writing "Do not remember." This may result in additional inquiries from the Director of the Ohio EPA or the Attorney General's Office, but it will avoid implication that you are trying to conceal information. However, you should not answer "Do not remember," or with similar words, simply because the information may not be immediately at hand. You are expected to make reasonable efforts to check your records so that you can answer the questions completely. American LegalNet, Inc. www.FormsWorkFlow.com SOCIAL SECURITY NUMBERS Notice required under Section 7(b) of the Federal Privacy Act of 1974 Under Section 7(b) of the Privacy Act of 1974, 5 U.S.C. Section 552a (note), any federal government agency which requests an individual to disclose his Social Security Account Number, must inform that individual whether the disclosure is mandatory or voluntary, by what statutory or other authority such number is solicited, and what uses will be made of it. Although not expressly bound by this provision, the Ohio Environmental Protection Agency and the Ohio Attorney General are authorized to request Social Security Numbers pursuant to Paragraph (D) of Section 3734.41 of the Ohio Revised Code, which defines content of the disclosure statements. The Social Security number is used as a secondary identifier by the Ohio Bureau of Criminal Identification and Investigation when they conduct background investigations of individuals listed on disclosure statements. It is used routinely to ensure correct identification when the Bureau of Criminal Identification and Investigat