Personal History Disclosure Form (Page 3 of 4) in pdf

Section 2 – Disclosure of Civil and Administrative Penalties

As used in this section, the phrase " violation of any law or regulation pertaining to the protection of the

environment" includes the violation of any local, state or federal statute, rule, regulation, order (judicial or

administrative), certification or permit relating to the generation, collection, transportation, treatment, processing,

storage or disposal of solid or hazardous waste, and to any local, state or federal statute, rule, regulation, order

(judicial or administrative), certification or permit relating to water pollution, air pollution, discharge of hazardous

substances, land use, wetlands protection, pesticide control, or toxic substances control.

Part A - Judicially Determined Civil Violations

List and explain all civil violations which a federal, state or local court, or a court of a foreign country, has

determined to have been committed by you, and list and explain any and all admissions made by you in connection

with any judicial proceeding, for any violation of any law or regulation pertaining to the protection of the

environment, the public health or public safety, or pertaining to the regulation of activities which affect the

environment, public health or public safety in any way whatsoever. Attach additional pages if necessary. Place

an “X” in the box below if there are no judicially determined civil violations.

NO VIOLATIONS

COURT: ________________________________________________________________________

LAW OR REGULATION VIOLATED: _______________________________________________

DATE OF JUDICIAL DETERMINATION: ____________________________________________

DATE OF VIOLATION: ___________________________________________________________

NATURE AND LOCATION OF VIOLATION: _________________________________________

PENALTY ASSESSED: $___________________ REMEDIATION REQUIRED: ______________

_________________________________________________________________________________

Part B - Administrative Violations

List and explain all civil violations which a federal, state, local or foreign administrative body or agency, or a

quasi-judicial body, has determined to have been committed by you, including those resulting in an assurance of

discontinuance or other form of consent decree, for any violation of any law or regulation pertaining to the

protection of the environment, the public health or public safety, or pertaining to the regulation of activities which

affect the environment, public health or public safety in any way whatsoever. Attach additional pages if

necessary. Place an “X” in the box below if there are no administrative violations.

NO VIOLATIONS

ADMINISTRATIVE OR QUASI-JUDICIAL BODY/AGENCY: ____________________________

LAW OR REGULATION VIOLATED: ________________________________________________

DATE OF ADMINISTRATIVE DETERMINATION: _____________________________________

NATURE AND LOCATION OF VIOLATION: __________________________________________

PENALTY ASSESSED: $_________________ REMEDIATION REQUIRED: _________________

_________________________________________________________________________________

Regional Offices – Barre/Essex Jct./Rutland/Springfield/St. Johnsbury

Personal History Disclosure Form Page 3