Laserfiche WebLink
Attachment B. <br /> <br />EUGENE TOXICS RIGHT-TO-KNOW PROGRAM <br />MATERIALS BALANCE REPORT CERTIFICATION FORM <br />Reporting Year 2012 <br /> <br />PRIMARY CONTACT INFORMATION: <br /> <br />BUSINESS NAME: <br /> <br />PROGRAM ID NUMBER: <br /> <br />BUSINESS ADDRESS: <br /> <br />MAILING ADDRESS: <br /> <br />PRINTED NAME: <br /> <br />TITLE: <br /> <br />PHONE NUMBER: <br /> <br />EMAIL ADDRESS: <br /> <br /> <br />By checking this signature box, I <br />hereby certify that the information <br />contained in the accompanying elec- <br />tronic materials balance report is <br />complete and accurate to the best of <br />my knowledge, based on readily <br />SIGNATURE:DATE: <br /> <br />available information. <br /> <br />PERSON COMPLETING REPORT IF DIFFERENT FROM ABOVE (NOT TO BE RELEASED <br />TO THE PUBLIC): <br /> <br /> <br />PRINTED NAME: <br /> <br />TITLE: <br /> <br />PHONE NUMBER: <br /> <br />EMAIL ADDRESS: <br /> <br />- 36- <br />