Ordinance No. 20499 - Laserfiche WebLink

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