DRIVER'S APPLICATION FOR EMPLOYMENT

Date of ApplicationApplicant Name

In compliance with Federal and State equal employment opportunity laws, qualified applicants are considered for all

positions without regard to race, color, religion, sex, national origin, age, marital status, veteran status, non-job related

disability, or any other protected group status.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and

other related matters as may be necessary in arriving at an employment decision. (Generally, inquiries regarding

medical history will be made only if and after a conditional offer of employment has been extended.) I hereby release

employers, schools, health care providers and other persons from all liability in responding to inquiries and releasing

information in connection with my application.

TO BE READ AND SIGNED BY APPLICANT

In the event of employment, I understand that false or misleading information given in my application or interview(s)

may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Company.

I understand that information I provide regarding current and/or previous employers may be used, and those employer(s)

will be contacted, for the purpose of investigating my safety performance history as required by 49 CFR 391.23(d) and

(e). I understand I have the right to:

Review information provided by previous employers;

Have errors in the information corrected by previous employers and for those previous employers to re-send the

corrected information to the prospective employer; and

Have a rebuttal statement attached to the alleged erroneous information, if the previous employer(s) and I cannot

agree on the accuracy of the information.

·

·

·

Signature Date

FOR COMPANY USE

PROCESS RECORD

APPLICANT HIRED

DATE EMPLOYED

DEPARTMENT

SIGNATURE OF INTERVIEWING OFFICER

(IF REJECTED, SUMMARY REPORT OF REASONS SHOULD BE PLACED IN FILE)

REJECTED

POINT EMPLOYED

CLASSIFICATION

TERMINATION OF EMPLOYMENT

DATE TERMINATED DEPARTMENT RELEASED FROM

DISMISSED VOLUNTARILY QUIT OTHER

TERMINATION REPORT PLACED IN FILE SUPERVISOR

This form is made available with the understanding that J. J. Keller & Associates, Inc.® is not engaged in rendering legal, accounting, or other professional services.

J. J. Keller & Associates, Inc.® assumes no responsibility for the use of this form or any decision made by an employer which may violate local, state or federal law.

© Copyright 2011 J.J. KELLER & ASSOCIATES, INC.®, Neenah, WI · USA

(800) 327-6868 · www.jjkeller.com · Printed in the United States15F (Rev. 1/11) 691

Lighthouse Environmental Services, Inc. P.O. Box 84152

Pearland, TX 77584Phone: (713) 987-0400 Fax: (713) 987-0410

APPLICANT TO COMPLETE(answer all questions - please print)

Position(s) Applied for

Name Social Security No.Last First Middle

List your addresses of residency for the past 3 years.

Current AddressStreet

State Zip Code

Street

Previous

Addresses

Street

Street

Phone How Long?yr./mo.

City

City

City

State & Zip Code

State & Zip Code

State & Zip Code

How Long?

How Long?

How Long?

yr./mo.

yr./mo.

yr./mo.

City

Do you have the legal right to work in the United States?

Date of Birth(Required for Commerical Drivers)

Can you provide proof of age?

Have you worked for this company before? Where?

Dates: From To Rate of Pay Position

Reason for leaving

Are you now employed? If not, how long since leaving last employment?

Who referred you? Rate of pay expected

Have you ever been bonded?(Answer only if a job requirement)

Name of bonding company

Is there any reason you might be unable to perform the functions of the job for which you have applied [as described in the

attached job description]?

If yes, explain if you wish.

EMPLOYMENT HISTORY

All driver applicants to drive in interstate commerce must provide the following information on all employers

during the preceeding 3 years. List complete mailing address, street number, city, state, and zip code.

Applicants to drive a commercial motor vehicle* in intrastate or interstate commerce shall also provide an

additional 7 years' information on those employers for whom the applicant operated such vehicle.

(NOTE: List employers in reverse order starting with the most recent. Add another sheet as necessary.)

EMPLOYER DATE

NAME

ADDRESS

CITY

CONTACT PERSON

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

FROM

MO. YR.

TO

MO. YR.

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

STATE ZIP

PHONE NUMBER

YES NO

YES NO

PAGE 2 15F (Rev. 1/11) 691

Email: _____________________________________________

EMPLOYMENT HISTORY (continued)

EMPLOYER DATE

NAME

ADDRESS

CITY

CONTACT PERSON

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

STATE ZIP

PHONE NUMBER

YES NO

FROM

MO. YR.

TO

MO. YR.

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

YES NO

EMPLOYER DATE

NAME

ADDRESS

CITY

CONTACT PERSON

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

STATE ZIP

PHONE NUMBER

FROM

MO. YR.

TO

MO. YR.

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

YES NO

YES NO

EMPLOYER DATE

NAME

ADDRESS

CITY

CONTACT PERSON

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

YES NO

PHONE NUMBER

STATE ZIP

REASON FOR LEAVING

SALARY/WAGE

POSITION HELD

FROM

MO. YR.

TO

MO. YR.

YES NO

EMPLOYER DATE

NAME

ADDRESS

CITY

CONTACT PERSON

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

STATE ZIP

PHONE NUMBER

YES NO

FROM

MO. YR.

TO

MO. YR.

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

YES NO

EMPLOYER DATE

NAME

ADDRESS

CITY

CONTACT PERSON

WERE YOU SUBJECT TO THE FMCSRs† WHILE EMPLOYED?

WAS YOUR JOB DESIGNATED AS A SAFETY-SENSITIVE FUNCTION IN ANY DOT-REGULATED MODE SUBJECT TO THE DRUG

AND ALCOHOL TESTING REQUIREMENTS OF 49 CFR PART 40?

STATE ZIP

PHONE NUMBER

YES NO

FROM

MO. YR.

TO

MO. YR.

POSITION HELD

SALARY/WAGE

REASON FOR LEAVING

YES NO

† The Federal Motor Carrier Safety Regulations (FMCSRs) apply to anyone operating a motor vehicle on a highway in interstate

commerce to transport passengers or property when the vehicle: (1) weighs or has a GVWR of 10,001 pounds or more, (2) is

designed or used to transport 8 or more passengers (including the driver), OR (3) is of any size and is used to transport hazardous

materials in a quantity requiring placarding.PAGE 3 15F (Rev. 1/11) 691

* Includes vehicles having a GVWR of 26,001 lbs. or more, vehicles designed to transport 16 or more passengers (including the

driver), or any size vehicle used to transport hazardous materials in a quantity requiring placarding.

DATES

NATURE OF ACCIDENT

(HEAD-ON, REAR-END, UPSET, ETC.) FATALITIES INJURIES

HAZARDOUS

MATERIAL SPILL

LAST ACCIDENT

NEXT PREVIOUS

NEXT PREVIOUS

ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MORE SPACE IS NEEDED) IF NONE, WRITE NONE

LOCATION

TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) IF NONE, WRITE NONE

DATE CHARGE PENALTY

(ATTACH SHEET IF MORE SPACE IS NEEDED)

EXPERIENCE AND QUALIFICATIONS - DRIVER

Driver

licenses or

permits held

in the past

3 years

STATE LICENSE NO. ENDORSEMENT(S) EXPIRATION DATE

A. Have you ever been denied a license, permit, or privilege to operate a motor vehicle?

B. Has any license, permit, or privilege ever been suspended or revoked?

YES

YES

NO

NO

IF THE ANSWER TO EITHER A OR B IS YES, GIVE DETAILS

CLASS

DRIVING EXPERIENCE CHECK YES OR NO

CLASS OF EQUIPMENT CIRCLE TYPE OF EQUIPMENT

DATES

FROM(M/Y) TO(M/Y)

APPROX. NO. OF MILES

(TOTAL)

STRAIGHT TRUCK

TRACTOR AND SEMI-TRAILER

TRACTOR - TWO TRAILERS

(VAN,TANK,FLAT,DUMP,REFER)

TRACTOR - THREE TRAILERS

MOTORCOACH - SCHOOL BUS

OTHER

(VAN,TANK,FLAT,DUMP,REFER)

(VAN,TANK,FLAT,DUMP,REFER)

(VAN,TANK,FLAT,DUMP,REFER)

More than 8

passengersYES NO

NOYES

NO

NO

NO

YES

YES

YES

LIST STATES OPERATED IN FOR THE LAST FIVE YEARS:

SHOW SPECIAL COURSES OR TRAINING THAT WILL HELP YOU AS A DRIVER:

WHICH SAFE DRIVING AWARDS DO YOU HOLD AND FROM WHOM?

MOTORCOACH - SCHOOL BUS YES NOMore than 15

passengers

EXPERIENCE AND QUALIFICATIONS - OTHER

SHOW ANY TRUCKING, TRANSPORTATION OR OTHER EXPERIENCE THAT MAY HELP IN YOUR WORK FOR THIS COMPANY

LIST COURSES AND TRAINING OTHER THAN SHOWN ELSEWHERE IN THIS APPLICATION

LIST SPECIAL EQUIPMENT OR TECHNICAL MATERIALS YOU CAN WORK WITH (OTHER THAN THOSE ALREADY SHOWN)

EDUCATION

CIRCLE HIGHEST GRADE COMPLETED: 1 2 3 4 5 6 7 8 HIGH SCHOOL: 1 2 3 4 COLLEGE: 1 2 3 4

(NAME) (CITY, STATE)LAST SCHOOL ATTENDED

TO BE READ AND SIGNED BY APPLICANT

This certifies that this application was completed by me, and that all entries on it and information in it are true and

complete to the best of my knowledge.

Signature: Date:PAGE 4 15F (Rev. 1/11) 691

Applicant Authorization to Release DOT Drug/Alcohol Test Results

Applicant/Employee: _____________________________________________ Company Name: LIGHTHOUSE ENVIRONMENTAL SERVICES INC. I understand that as a condition of hire with the above named “Company”, that I must consent to the release of all DOT mandated drug and alcohol information from all of the employers for which I worked in a DOT safety-sensitive position, or for which I took a DOT pre-employment drug test, during the previous two (2) years as required by DOT Part 40.25, (or three (3) years as required by Part 391.23 for any driver of a commercial motor vehicle). Pipeline Testing Consortium, Inc. (PTC), acting as the agent/representative for the hiring Company, will receive the information.A Commercial Driver’s License (CDL) is required for my employment: No Yes Check boxesonly if applicable

I have NOT worked in a DOT safety-sensitive position for a DOT regulated company in the past 2 years (3 years for CMV drivers, 5 years for pilots). Proceed to sign and date form below.

I have tested positive, or refused to test, on a DOT pre-employment drug or alcohol test for an employer who did not hire me in the past two years (3 years for CMV drivers, 5 years for pilots). Please specify the company for which this occurred below.

I hereby authorize the following previous employer / company to furnish to PTC the DOT information requested in section 2 below.

Previous DOT Employer: ______________________________________________________________________

Address: _____________________________ City: ___________________________ St: ______ Zip: _________

Phone: ____________________ Fax: _______________________ E-mail: ______________________________

Contact: _________________________________ Dates of Employment: _______________ to ______________(Complete additional form for each previous DOT employer)

Certification: I have read and fully understand this authorization to release my previous drug and alcohol test information, identified by the questions below, to Pipeline Testing Consortium, Inc. I hereby acknowledge that failure to provide accurate information in response to this request for release of information could negatively affect my employment offer or subject me to disciplinary action up to and including termination if later discovered after my employment with the Company begins.

____________________________________ ____________________ _________________ Signature of Applicant SSN Date

Release of Previous Employer’s DOT Drug/Alcohol Testing ResultsSECTION 2: TO BE COMPLETED BY PREVIOUS EMPLOYER

In accordance with DOT regulations, the Company, named above, is required to obtain -- and as a Previous Employer, you arerequired to release -- DOT drug and alcohol information, listed below, concerning the Applicant/Employee, named above. This information request covers any period of employment of the Applicant/Employee by you going back 2 years (3 years for CMV drivers), from the date of this request. Please complete the following:YES NO_____ _____ 1. Any DOT alcohol test results of 0.04 or greater?_____ _____ 2. Any DOT positive drug test results?_____ _____ 3. Refusal to submit to a DOT required drug / alcohol test? (incl. adulterated or substituted results)

_____ _____ 4. Other violations of DOT drug and alcohol testing regulations?_____ _____ 5. Did a previous employer report a drug / alcohol rule violation to you?____ _____ 6. If “yes” for any of the above items, did the employee complete the return-to-duty process?*

7. Was the Applicant/Employee employed by you but NOT subject to DOT regulations?*Note: If “yes” for item 5, you must provide the previous employer’s report. If you answered “yes” for item 6, you must also transmit the appropriate return-to-duty documentation (e.g., SAP report(s), follow-up testing record).

_________________________________ ___________________________ ___________________ ____________ Name of Person Completing Form Title Phone Date

*A reproduction of this authorization shall be deemed as effective and valid as an original. Rev. 2016

Fax completed form(s) to the PTC HISTORY CHECK DEPT # 620-665-6376 orE-mail to: history@pipelinetesting.com

SECTION 1: TO BE COMPLETED BY APPLICANT

Phone: (620) 669-4484 E-mail: history@ptcassist.com

www.ptcassist.com

FMCSA - Applicant Authorization to Release Safety Performance History(As required by 49 CFR Parts 40.25 and 391.23)

Acct. Code: 1511PTCName of Applicant:

___________________________________________________ Social Security #: Date of Birth:

I do hereby authorize you to release the following information to the below named “Company”,

LIGHTHOUSE ENVIRONMENTAL SERVICES INC.(and, if applicable, its respective agents or consortium/third party administrators) for the purposes ofinvestigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations.

Check this box if you have NOT driven a commercial motor vehicle in the past three years.

Signature of Applicant Date

Previous Employer:

Address:

City: ST: Zip:

Phone #: Fax #: Email:

Position: Start Date (mm/yyyy) End Date (mm/yyyy)

In accordance with Section 391.23, we are obligated to request the information below from all previous employers of the applicant that employed him/her to operate a commercial motor vehicle (over 26,000 lbs) within the 3 years preceding the date above. Please complete the information below and return to us within 30 days, as required by Section 391.23(g). Please phone/fax/mail or email the following information to:

PTC Assist, LLC9 Compound Drive, Hutchinson, KS 67502

phone: 620-669-4484 fax: 620-665-6376 email: history@ptcassist.com

Safety Performance History:Did he/she drive a commercial motor vehicle for you? Yes NoIf Yes, what type? Straight Truck Tractor-Semi trailer Bus

Cargo Tank Doubles/Triples Other (specify)

Reason for leaving your company: Discharged Resignation Lay Off Military Duty

Check if there is no safety performance history to report, sign below and return.Accidents: Complete the following for any accidents included on your accident register (390.15(b)) that involved theapplicant in the 3 years prior to the application date shown above.

Date Location No. of injuries No. of fatalities Hazmat Spill 1. 2. 3.

Enclosed is other accident information pursuant to the employer’s internal policies for retaining minor accident information (391.23(d)(2)(ii)).Any other remarks: .

__________________________________ _____________________________ __________________ ____________ Name of Person Completing Form Title Phone Date

Keep a record of this request and the response for one year.

E-mail completed form(s) to history@ptcassist.com or via fax: 620-665-6376

* A reproduction of this form shall be deemed as effective and valid as an original. (Rev. 2018)

TO BE COMPLETED BY PREVIOUS EMPLOYER

REQUEST FOR CHECK OF DRIVING RECORD

I hereby nulhollze )'OU to release 1ho following lnfum1allo11 to Lighll1ouse Environmental Ser\'icl!s for purposes of Investigation as required by Sections 391.23 8Jld 391,25 ofU1e Federal Motor Canler Safety Regulolions. You rue released from any a11d all l!abillty which may 1esull from ti.lmlshlng such lnfonnatlon,

(Appllunt's Sfgn11furc) (Dale)

In accordance with the provJslons of Secllons 604 and 607 of the Fair Credit Reporfiag Act, Publio Law 9 l �508 as amepded by lho Consumer Credi! Reporting Ac! of 1996 (filloll, Sublille D, Chapler I ofPublloLaw 104-208), I hereby certify lhe following:

o.) lheco�{!Q\er(appll�t) h� aull!oriz�4 in writlng the pro�u�ement oftJ1is report; b.) tho oonsumcr(appHcant) has been iuformed in a sepaiolo \wiUei:t disclosure that nconsurrtcr rcportn1ay be obtained for employment purposes; c.) tho lnformallon requc.s!ed below will b� used Cot a "penoisslblo purpose" (i.o., information for employment purposes) and will be used for no other purpose; d.) the infonuaHon being obtained will uol be used ln violation of any federal or state eq_ual Opportunity law or regulalion; and

.... �.->.. �f���-!��i-�.��Y-�!����?�.��e� -�-��l�_o_le o_� i�-��-�n _th� ��o� �� ��suniec (applicant) will �ccelve a copy of Lhe­requesfed report and tlie sunuuary of cons,\mer nghls as provided with lhe- repO(t by thtfC{ffiS-Ufllet reportmg agency: ·· · ·- · · ··· · ·-

( also he,eby certify that this report request and the above applicant's release notice meet the defmition of"pennissible uses" of sfale molor vehicle records undetthe provlslons of the-Driver's Privacy r,oledlon Act of1994 [Public Law l03K322, Title XXX, Section 300002(a)).

(Signature of Requester) (Dale)

TO: _________ _

'fO WHOM IT MAY CONCERN: D TI1e following named person has made application with ou< company for the posilion of drlvc1·. In accordance with Section 39 l.23, Federal DepartmentofTrrmsportotlon Regulalions, please furnish the underSig:ned with the applicant's driving record for the past lhreeycars.

NAME OF APPLICANT/DRIVER ____________________ _

DATE OF BIB.TH _____ _ SSN ______ _ LICENSE NO. _____ �

ADDRESS ____________________________ _ (Nnn1ber&Slrcel) (Cily) (Slale) (Zip.Code)

FORMERADDRESS ________________________ _ (Nnmber&S!reel) (Clly) (Slale) (Zip Code)

REQUESTED BY

Lighthouse Environmental Services (Please Print or Type Name)

4904 Fuqua (fllle/PostHon)

Houston, Texas 17048 (Signature)

MOTOR VEHICLE DRIVER'S

CERTIFICATION OF VIOLATIONS/ANNUAL REVIEW OF DRIVING RECORD

MOTOR CARRIER INSTRUC110NS: Each molor Cll.I1icrsha11 nl least once<wcry 12 months, require each driver it employs (o prepare and furnish lhe motor carrier with a llsl ofa..11 violalions ofmolor vehicle traffio Jaws and ordlnMces (other tJ1an violations involving only paddng) of which tho driver has been convlc!ed, or on a«:ount of which he or she has forfeited bond or collalecal during the preuding 12 months (Seclion 391.27). Drhws w110 ha\'e provided infomrnllon required by Seelion 383.31 nwl nol repeat lbat lnfomrntion on this fonn.

DRIVEn nEQUIItEMENTS: Each driver shall fun1lsh the list n.s required by tho molor carrier above. If tho driver has not been convicled of or forfeited bond or collateca1 on aocount of any violation wh!ch must be Us!ed, he or she shall so c,ertlfy (Section 391.27).

*COMPl1ETED BY DRIVER-CERTIFICATION OF VIOLATIONS*I

NameofDrlvec: (Print) --;------------ SSN: ________ _ Employment Dote: ____ _

Honie Terminal ---------�(Cii)•) ' (Slate)

Driver1s License No. ______ State __ Expiration Date: ___ _

i I certify lhat the folloivlng is n frlio imd cori1pleto list of traffic violalloiis required to be !isled (ii!liir that tliose I l1a1•e provided under Port 383) fol' which I hnvo been convktcd or forfeilcd bond or collntcrnl during the pnst 12 months.

DATE OFFENSE LOCATION TYPE OF VEffiCLE OPERATED

I HA VE HAD NO VIOLATIONS.

If no vlolatlons nro listed above, I certify that I havo not been convicted or forfeited bond or collateral on account of :my .. violation (other than those I bovo provided undeJ'-Part 383)requlred to bo llsted during the past-12 months,-

Dato of Cerlificnllon _________ _ Driver's Slgnnhtrc ______________ _·- · -·-·-·-·-·-·-·- · - · - ·- ·-·-· - ·-· - ·-·-·-·- · - · -

*COMPLETED BY MOTOR CARRIER-ANNUAL REVIEW OF DRIVING RECORD*Motor Carrier lnslruclions: Reyiew the aboYc listed Certification ofViolalions and other infoimation described In Section 391.25 of the Federal Molor carrierSafetyRcgulalions. Compfelc the information requested below.

I have hereby reylewed the driving record of the driver named above in acrordance with Section391.25 and find lhal he or sho: (checkono)

___ Meets minimum requirements for safe driving

--=-= Do� not adequately meet satisfactory safe driving performance ,.

___ Is disqualified to drive a motor vehicle pursuant to Section 391.15

ActtoJ] lakenwithdriver: ------------------�-----�-------'-

Reviewed by:----��---------­Signature

Printed Nantc

Llehthouse Em•lronmental Services Company Name

Date

Title

4904 Fuqua St Houston Tx, ?7048 Company Address

REQUEST FOR INFORMATION FROM PREVIOUS EMPLOYER

I hereby authorize you to release the following requested information to: Lighthouse Environmental Services for the purposes of investigation as required by Section 391.23 of the Federal Motor Carrier Safety Regulations. You are released from any and all liability which may result from providing such infojation.

(Dale) (Applicant's Slgoafurc)

Mall or Fax To:-- -(Previous Employer Natne): __________ --__---_ -- -- D Fi�st R�<J��t I (Attention):(Phone): (Fax):

To Whotn It May Concern:

Date;____ ____ _ D Second Request

Date _____ _

The individual named below has made application to this company for a position as a d1'il'c1· and states that he/she was employed by you as a drive,· from __________ to ___ =�����---

(OOte of /,/re) (dale of fen11fnatio11)

We do appreciate your time in completing, in confidence, the information requested below. A business reply envelope has been enclosed for your convenience, or you may return the information via fax lo the attention of DOT SAFETY DIRECTOR al fax number listed below. Thank you for your cooperntlon.

·

Sincerely,

.. --------·--�---------------------------------------------------------------------------------

NAMEOFAPPLICANT: _____________ _ SSN: _______ _

1. Bnipfoyedfrom _______ lo ______ as _________ .atsalazyorwageof S _____ .

2, Did be/she dri,·e a motor yehicle for you? Ye.s _No ....---, Straight Truck? Yes_ No __. Trn�tor..SentilJ'ailer? Yes_ No_ Biis?Yes_-_-·No_. oilier'l(Specify) -

-- ------ - - ·- - - --- - - --

3, Washe/sheefficientandasafedriver? Yes __ No __

4, Wf1:S.W.s/J1ergenera1 conduct satisfactory? Yes __ No __

5, Reason he/she left your company: Discharged___; ResJgnallon ____; Lay Off___; Mililary Duty __

Page 1 ofZ

Pago 2 of2

Please Indicate yow· opinion by placing a checkmark in the appropriate colulllll.

CHARACTERISTICS

Dlsposilion, Tac� Abilily lo gel along with others

Jnit/allvo. Resour�fulness

Safely Habi�

Driving Skill

Attitudo

L-Oyally

BXCELLENT GOOD FAIR POOR

Additionalcollllllenls ______________________________ �

Request for Information Related to Alcohol & Controlled Substances Tesflng

During our employment, the above uamed applicant:

_ Had no violations to our alcohol aud controlled substances policy.

_ Hnd ccnfinned positive controlled substance test(s).

_ Had confirmed blood alcohol test(s) resulting in a blood alcohol concentration greater than .04 (Br AC).

Refused to submit to au alcohol or controlled substance test.

Slgnatm·e of Previous Employer Representative ______________ _

Title of Previous Employer Rcpmentallvo ________________ _

Dato ___________ _

RELEASE & DOCUMENTATION OF PRE-EMPLOYMENT TESTING INFORMATION BY APPLICANT/DRIVER REQUIRED BY Part 40, ,250)

. '

PART 40.25(1) requires Employers to ask Applicant/Driver whether he/she ;has tested positive or refused to test on any Pre-employment alcohol or dmg test administered by an Employer to which the Ap).Jlicant/Driver aiiplied but dicl not obtain safety sensitive transportation work covered by DOT agency alcohol and ch;ug testing rules during the past two (2) years,

NAME ..... -.-.-.. -.. ---=:-,---:=c=c:c=-:=c-:cc.-... cc ... c:c .. -::c .. c:-.. =-=

])t\ 1:8.-... -... -.. ·=···-·· .. -.• -.. -=----�-

SOCIAL SECURITY NUMBER _________ _

Applicant/Driver to answer items listed below.

During the past two (2) years have you fe,sted positive on a Pre-employment alcohol or dmg to!t administered by Employer to which you applied for but did not obtain a safety sensilive transportation work covered by Department of Transportation (DOT) dmg and alcohol testing mies?

YES_____ · NO _____ _

During the past two (2) years have you refttsed to fest on a Pre-employment alcohol or dmg test administered by Employer to which you applied for but did not obtain a safety sensitive transportation work covered by Department of Transportation {DOT) dmg iind alcohol testing rules?

· ···· ···· ·· ····· ··· ····· ··· ·· ····· · ·YES · · - · · NO· -------

Ifyou answered YES to eitlier of the questions above, please 'provide documental!on of your successful completion of the return-t?·duty process required by Part40 Subpart 0,

Date ___ ! __ ....,/��-(llfontb) (D•y) (Year)

(Signature of AppfkanllDlinr)

Name -----=c---=-7""7-----

(P I e .as e Prlnl)

(Wflnm Signature)

Record keeping requirements: If"YES" to elther question- 5 y_ear retention, If "NO" to both questions- discard after emplo)'))lent tenninates,

DRIVER'S STATEMENT OF ON-DUTY HOIDl.S (For Newly Hil'ed Drivers)

Federal Motor Carl'ler Safety Reg11lat/011s- § 395,8 (j) (2)-Motor Carriers, when using n driver for lhe first time or intermittently, shall obloin from the driver a sigoed statement giving the total time on duty during the Immediately preceding 7 days and lhe time at which the driver was lasl relieved from duly prior to beginning work for the motor carriers.Note: Hours for any compensated work, Jncludlng work for a non-motor carrier entity) must be recorded on this form.

*Please Print*

Drive,· Name _____________ _ Soefal Securlly No, ________ _

Driver'sLlcensc: State ___ _ Number -----�--- Class __ _

Endorscmcnt(s) ____ _ ResMctlon(s), ____ _

Type of License _____ _ Issuing State' ____ _

DAY 1 2 3 4 5 6 ()'uferday)

"DATE

HOURS Tot"/ Hours WORKEl

---------·--- " ...... ··-·-------·-- -------- --- -- ---- --thereby certify that !he infomrntion given above is correct to the best of mylmowicdg,i,iiiil-J.iefiefand thnt I was last relieved from work al --,,c--,,---AM PM on

(Ilme) -�(D�,,�) -�(/>�!o-nl�b)�(V-.,�,)�

Date

Fe,lera/ Alo/or Carrier Safety Reg11/at/011s -§ 395,2 (8) nud (9)- On duty time means all time from the time a driverbegins to work or ls required to be in readiness to work until lhe linie the driver is relieved from work and all responslbllily for performlJJg work. On duty ti rue shall !nclude: · (8) Perfomtlng aay otlier work in Iha capacity, eruploy or service of a motor carrier; and(9) Perfomtlng any compensated work for a person who ls nol a motor carrier.

Are you currently working for another employer?

At this ttnie do you lntenH to work for another employer while still employed by this company.

Yes

Yes

No

No

I hereby certify that the Information given above Is true. I also uuderstand that once I become employed withthis company lfl begin working for any additional employer(s) for compensation !bat I must lmmedlntely Inform this eompnny ofsueh employment activity,

Drh·tr'.s Signature

Witness:---�-��-��-----­Company Repmenlatire

Dafe

Dale

Part 6 • Passing and Turning In Traffic

A, Turning Gels lnlopr�...flan6W<'?J [fl M·,a1100 O[I\NT Ched;s�cor.ft!ons&ttxnsM)

wh�ln!met-liOOls dea, Signafs Intent'«'! lo Wm wen In adv�rrA ¼hen preparl<lg lo C001f{elt1 flghl hand tum,

resV,ffl lraffiofrom pm!ng oo "9trPr❖nlplJ/ oomp!etes fum tMclf Wv.il.hw

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B, Signs and Sfgnils Is pre pated to stC{l v.hen awroa�ng �!g11aJ OOOys IJofflo t!gMi Us� good jlJ4.grnet1lepPfo.&clt1'19 yello-!1 fight Notlw-s and hte-ds t,aff.;;i tOM, lrldu<fn.J 510F '""'

C, lnlersttllons Slows {o petn\l $!0f'f>'.ng if lle«!$-S3f) lot>lt.s {Ol («ISS lra!W,'iflh OI 'Mthout

frnliiccoo!roU Yields rlghl-of.way fer safe!)

o, orade Cro»ln9s K,wns Md lmm!aM's r�rnl and sl�te ru!(I.S

�'lwr.'f\9gral$s«oH!ngs · Miii.fffta'fllijp. lfre<flii�r. ·~ s�eds p(oper giai Md �s ool shift rie�t

\'<h1&ctOH!t,s M;vsls Sf-eedto �1)00

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Aftw;s svflidenl 10001 when re!urrlng to ffglJ '"''

O!hi.'IS

�nol f0<caway thrOOJh lraff.o or (tl'.t'NdotMrdrivera

Us:u horn wJ-;wh-!n n��ssa.iy Coorieoos drl\� and us1Js pr�r o:ina'uct

Part 7 - Miscellaneous Sta-Js a!W: utd aHw,t,'vo Atf;l.1$1.s diMng lo m1J,i;{ciwt!Jr.;J

OOO<f.Gons Perfonns r«Mng fuoct!MS l-lith◊Ut I�

6'/« off road R� ch«& lns!rumenl pan� Takeslnst<w.ions Md suwesl!o(ls "'""''

Stlfconf.<k-111 lo drlv'.n� c»o.s not d"sp!'ay 1oi:d raS!); pos'ffi•a

aB!uda Plop¢J d\w:s rr�,t,I Plord-rft hand!es snd loads tre!ghl Pl()f)Mt haM.�s IY:Us lke&sd<!fmlOad QS !�tiled Oispf�s mcthfedge of oompan:, rules Dlsptil)'Sl<Mh1edga off�ral. s!a�e,

ao.:ilocalcegijat,)fls O:spt�ys M0',\1� of sped al true,< 1ou!ei

1:1se « Spedal t:qtipmeni (SpiciM · ·

General Pen'onnanee: Sali1,factoc:, Ne-edsTm'n.'Jl,J U1mU$foct'«y

Qualified to Drive: Trud< Tractoc-SerrJ!ta�er Olhef{s�fy)

REMARKS:. ___________________________________ _

S!gnaluro of Exemfner

CERTIFICATION OF ROAD TEST §391.33{0){9) If lhe road t�lls suo:essM)'(.O!"llj'.{e!ed, lM �\\M gavo ltsha!loxr,plele a �fle.:i!o of<lm�(sroad fesl Aoor,yol too

«rufiea!e sh..il 00 s,\'en to tM pe<SOOWho was e.l:'.afruled. Toe roo!or c::amet shaD ,eta!n fn !he d!iYef qua!tical'oo r.Ie of lhG pe1son v,·h was examl(!ed (1) U,e otlg',nal or 1M $/gMd road le.sl form (2) 1M �� °' a oopy of, ceftif-caliM of roa<I test requlr�

Olfve(sName, ______________ _ Op1mlo(s or Chauffeui's LI«Jnse No. _______ _ TypsofTraler(s) ___________ _

Social Sewrity Nu«iber, ____________ _ Slato___ 1'ypo of Power Unit _________ _ If passenger came,, lypa of bus. ___________ _

This Is to certify that the above.named driver was glven a road lest under my supeMston on,---------� 20_ conslsUng of app10:Jrnately ____ rniles of dlfving. II Is my o:mstdered opinion that this drive, possesses sufficlont dlfving skill to opetate safely the type of commerd:d motor veh!da tis-tad above.

(Om

(01oan1Ullon ofEnmlnu) (MdfHS('ffxamW-1)

Th_ls form was provided �y C9mpiJ:s� Cqmpllar:ice M.a.nag�ment/ (3.18) 512-1142 / \V\V\Y,compasscompllance.com

PRE-EMPLOYMENT URINALYSIS AND BREATJI ANALYSIS

CONSENT FORM

I understand that as required by the Federal Highway Administration Regulations, Title 49 Code of Federal Regulations, Sectioi1 382,301, all drivcr-ap11lic11nts of this employer must be tested for controlled substances and alcohol as a 11rc-condition for

'

em11loyment.

-1 clfilscnttotlie·ur)mfsiHtii>le·collectiiiti

ii111rtestiiigfoicoiifrolledsulist�nccs·�-!1(l

t1o breath sample collection and testing for alcohol.

I unclerstand that a verified positive test 1·csult for controlled substances ancl/or nn alcohol concentrntion of 0,04 01· higher will render me unqualified to operate a co!Ilil1ercial motor vehicle,

The medical review officer will maintain the results of my controlled substance test, Negative and positive results will be 1·eportecl to the employer, If the results are positive, the confi-ollcd substance will be illentificcl.

Alcohol test results will be maintained by the employer.

The results will not be released to any other parties without my written authorization,

Jmllferstrmd tlte above couditlons a/Id hereby agree to comply with tl1em.

(AppUcant's Name-Print)

(Appll1int's Sign a lure)

--=-c-=�'-=....,.----''-�-(Monlh) (Day) (Y<ar)

POLICY STATEl\tIEN1,

Lighthouse Environmental Services recognizes that our employees are our greatest asset. Om employees are the key to reaching 0\11' goal of providing the best products and setvices to Olli' customers. To achieve our goal, and to mllXimize the skills and talents of our employees, it is impoliant that every employee of Lighthouse Environmental Services understands the dangers of drug and alcohol abuse and be a,ware of the most recent state and federal requirements concerning substance abuse. This Policy and Procedure guide should not be consti:ued as conlrachml in �ny nahtre.

POLICY OBJECTIVES

· ---- -·-••-- . -··· - ····- ... - "' •·- -· -- ... ·-· ·-·- --- ···, -- ---····-···· ... .. . . -· .. ---

!. To create and maintain a safe, chug-free working environment for aliemployees. · .

2. To encourage any employee with a dependence on, or addiction to,alcohol or other drngs to seek help in overcoming the problem.

3. To reduce problems of absenteeism, tardiness, carelessness and/orother unsatisfacto1y maters related to job pe1fonnance.

4. To reduce the likelihood of incidents or accidental personal injuryand/or damage to customers, visitors or property.

5. To meet the requirements of the federal DOT Workplace Drng TestingProgralllS found in 49 C.F.R. Prut 40, as amended, and the FederalMotor Carriers Safety Administration (FMCSA) fmmd in'49 C.F.R .

..... P.mtJ$.2... ........... _ ··································•·-• .. ... ............... ___ .. _ ........... _ .. . ..... .6. To mitumize the likelihood that company prope1ty will be used for

illi�it drng activities. ;7. To protect the reputation of Lighthouse Environmental Services a'nd its

employees within the community.

Substance abuse can be a serious threat to Lighthouse Envirollll1ental Services, its employees and customers. Though the percentage of substance abusing employees may be relatively small, practical experience and.research indicate that appropriate precautions by Lighthouse Environmental Servic'es are necessary. It is the belief of Lighthouse Enviromnental that the benefits derived from the policy objectives outweigh the potential inconvenience to employees, Lighthouse Ehvircinine1itill Services eanlestly solicits the understanding and cooperation of all of its employees in the implementation and enforcement of this policy.

PROHIBITIONS

Lighthouse Environmental Services requires that all employees report to work without any alcohol or illegal mind-altering substances in their systems. Employees are also prohibited from using, possessing, manufacturing, distributing, or making arrangements to distribute unlawfol drngs while at work, on Lighthouse property, during breaks, or in Company vehicles.

No employee shall report to work Ol' remain on duty requiring the operation of a motor vehicle, other hazardous equipment Ol' perrormingjob duties in a hazardous enviromnent when the employee is using any controlled substance, except when the usc is pursuant to the instrnction of a physician who has advised the e1nployee that the substance does not adversely affect the employee's ability to perform in a s_afe mannei·, N:<! employee shall use alcohol while on duty. No employee shall perform any job-related duties within four hours of using alcohol. Fmiher, outside conduct of a substance-abuse related nature which affects the employee's wor� Lighthouse's relationship with govenllllent agencies or reflects poorly on

.... ....... I,ig_lltllo!Jse_�nyhCJ111n_e11tal Seryi�es is P1Q!iilii1�d, ..

Employees 'must inform their supervisor or the Company's Medical Review Officer (MRO) when they are legitimately taking medication which may affect their ability to work in a safe manner in order to avoid creating safety problems and violating this Drug and Alcohol Policy. The law treats the abuse of prescription medication as unlawful drng use.

The Company's Medical Review Officer (MRO) is Dr. David Paine MD. He may be reached at 7 Compound Drive, Phone 866-359-0414.

. ENFORCEMENT

In order to enforce these rules, Lighthouse Environmental ?ervices reserves the right to require all employees (defined as all employees supject to the FMCSA regulations found in 49 C,F,R. Part 382, as well as, all other employees subject to testing under the autho1ity ofLightl1ouse to submit, at any time an employee is on duty or at any time an employee may normhlly be called tci be on duty, to drug tests to determine the presence of prohibited substances. Lighthouse Envirolllllental Services is also required to develop, in1plement and enforce a drng and alcohol policy for their driver-employee� as a condition of compliance with the FMCSA regulations.

Pursuant to Lighthouse Environmental Services polioy and regulations, applicant testing may be required, All current employees may be required to undergo testing at scheduled physical examinations, where Lighthouse Enviromnental has reasonable suspicion to believe an employee has violated its Alcohol and Drng Policy, and on a random basis �vithout advance notice. Employees are also required to report all injury 01· damage related accidents involving Company

Lighthouse Environmental Services requires that all employees report to work without any alcohol or illegal mind-altering substances in their systems. Employees are also prohibited from using, possessing, manufacturing, distributing, or making arrangements to distribute unlawful drngs while at work, on Lighthouse property, during breaks, or in Company vehicles.

No employee shall report to work or remain on duty requiring the operation of a motor vehicle, other hazardous equipment or performing job duties in a hazardous environment when the employee is using any controlled substance, except when the usc is pursuant to the instrnction of a physician who has advised the e1nployee that the substance does not adversely affect the employee's ability to perform in a safe manner.' No employee shall use alcohol while on duty. No employee shall perform any job-related duties within four hours of using alcohol. Further, outside conduct of a substance-abuse related nature which affects the employee's work,' Lighthouse's relationship with government agencies or reflects poorly on

.. Lightho11s(l �nvinmmental Services is JJrohibited ...

Employees ·must inform their supervisor or the Company's Medical Review Officer (MRO) when they are legitimately taking medication which may affect their ability to work in a safe manner in order to avoid creating safety problems and violating this Drng and Alcohol Policy. The law treats the abuse of prescription medication as unlawful drng use.

The Company's Medical Review Officer (MRO) is Dr. David Paine MD. He may be reached at 7 Compound Drive, Phone 866-359-0414.

ENFORCEMENT

In order to enforce these rnles, Lighthouse Environmental �ervices reserves the right to require all employees (defined as all employees supject to the FMCSA regulations fom1d in 49 C.F.R. Prut 382, as well as, all other employees subject to testing under the authority of Lighthouse to stJbrnit, at any time an employee is on duty or at any time an employee may normally be called to be on duty, to drug tests to detennine the presence of prohibited substances. Lighthouse Environmental Services is also required to develop, implement and enforce a chug and alcohol policy for their driver-employees as a condition of compliance with

,,

the FMCSA regulations.

Pursuant to Lighthouse Environmental Services policy and regulations, applicant testing may be required. All cmrent employees may be required to undergo testing at scheduled physical examinations, where Lighthouse Environmental has reasonable suspicion to believe an employee has violated its Alcohol and Drug Policy, and on a random basis without advance notice. Employees are also required to report all injury or damage related accidents involving Company

property or personnel or during Companycrelated activities and may be required to submit to alcohol screening within eight (8) hours and to drug screening within thirty-two (32) hours of a repmtable accident. Employees who return to work following rehabilitation will be required to tmdergo return to duty/follow-up testing in addition to the general Company testing requirements, Additionally, any employee absent from regular job activities and duties for a period greater that twenty-one (21) days will also be subject to retum to duty testing, A repmt of a negative drug test result to Lighthouse Envirotllllental Se1vices Designated Employer Representative by the MRO is a condition of reinstatement. of the employee to a position of active employment.

Violation of these rules, including testing positive, will subject the emplbyee to discipline, up to and including discharge, Pursuant to Lighthouse: policy, Lighthouse Environmental Services will presume that au employee with a breath alcohol concentration (Br AC) at or above .04 is "under the influence" of ,alcohol, and he/she will be immediately removed from duty and will be subject to

.. disdpline; up io . and 1.ncltidirig. i.iiiiiiediit!e discliilrge, ·' Reftisal to coopel'ate with Lighthouse Environmental Setvices in any test, investigation, search, or paperwork. or consent form, will result in discipline, up to and including immediate discharge. Possession of, distribution of, or consumption of unlawfol or abused drugs, unauthorized alcohol, or drug paraphernalia, or unlawful conduct on or off duty, will also result in discipline, up to and including immediate discharge.

All infmmation, interviews, reports, statements, memoranda and test results, written or otherwise, received by the employer through its drng and alcohol testing program will be treated as con.fideniial communications and may not be used or received in evidence, obtained in di�cove1y, or disclosed in any public or ·private· proceedings· except in ·accordance· with the Consent/Release· Form; and -whenever necessaiy for Lighthouse Environmental Se1vices to defend itself in anyadministrative or civil proceeding,

Any questions should be directed to the person assigned as the Company'sDesignated Employer Repre�entative (DER), At the time of implementation ofthis policy, the DER is Sandy Roberts.

Substance Abuse Resources

Information Hotlines Alcoholics Anonymous (AA) 800-356-9996Amedciin Council on Alcoholism Helpline 800-527-5344Cocaine Hotline 800-347-8998National Council on Alcoholism 800-NCA-HELPNational Institute on Drng Abuse Hcitline (NIDA) 800-662-HELP Narcotics A.nonymoiiif-

--- ·- -· I

.. - . ·soo:33g:ff'151fAl-Anon 800-356-9996 Narc-Anon 213-574-5800

National Association of Alcoholism & Drug Abuse Council (NAADAC) 1911 N. Ft. Myer Dr., Suite 900 Arlington, VA 22209 703-741-7686

RELEASE OF DEPARTMENT OF TRANSPORTATION (DOT} DRUG TESTING RECORDS

ro Bil TR/\N$rl:RRED TO rne DRUG TESTING PROGRAM ADMINISTERtD tlY PIPEI.INE TE8llNG CONSORllUM, INC.

o COMPOUND DRIV!lHUTCHINSON, KANSAS 07502

(020) ooo.aooo

11GHTHOUSE ENVIRONMENTAL seRVICES, INC.

I '"'"",_,�,....,.,---.-.-.-.-. oulho1lze U1a oompany lo roloasa Iha rouowlng lnronnallon on my participation In Iha oompnny's alcohol ond drug testing program to PIPELINE TESTING CONSORTIUM, INC.

1. 'rflo stortlng ond ondlng dale of my participationIn tho compnny's alcohol and dnrg losllng p1ogmm.

2. All alcohol and drug losllng rocords 10 Include:

A) b) o) d) o)

ii

Nomo of !ho omployoo submHled lo a alcohol ond/ordnrg 1881; IJnlo !ho nloohol and/or druu last was conducted; Looallon or lho alcohol and/or clfug lesl; Lab thnl por/onriad tho nnnlysls; Tosi oalO{Jory: Subslnnoos tosted ror, Rosulls of tho alcohol ond/ordrug tosl: Tho lndlvklual soivlno OS MRO.

TIJO•• reco,ds nro rtiqulred to be mnlnlol11od under (RSJ>A) • 40 CFR Part 199 and (f'HWA) • 40 CFR Port 302 nnd oro l!alng rolaase<I lo aCMmpllsh tills roqulromenl.

.... exoautod lhlstha•cc--==:=:.·· ·dnyof· ... ... .. · ···· · .... · -- - ----;·20· -----

Employee Noma (Please Print)

Eimployeo Slgnatnro

Social SocurilyNumbor

"""HNOT£:: A,fACH COPIE..'1O11 BATFOllM, LAB AND MRO Rl:PORT""-

LIGHTHOUSE f;NVIRONMENTAL SERVICES INC. APPLICANT ALCOHOIJDRUG SCREEN ACKNOWLEDGMENT

1. t understand that the e-0mpany has a policy (as per U.S. Department of Transportation 49 CFRPart 199. 382 and Part 40) requlrtng each applicant for employment lo bo tested for tho presence or alcohol and/or drugs.

2. I under.;tand that the required specimen wlll be tested by a Department of Health and HumanSeNlcas (DHHS) certified laboratory for martJuana, oocalne, opiates, amphetamlnos, and PCP. Aloohol tos\lng will bo accomplished 1rtlllzlng breath tesllng equipment on the National Highway Tra!Oo Safety Admlnlstrallon (NHTSA) confom1lng Products Lisi.

3. I understand that Iha specimen will be tested to delem1lne !he presence of these druos andalcohol using a chain-or-custody procedure lo Insure lnlegrlly of the specimen and 11s ldenllllcallon .

. ... . - . . ... '.i:· - -· l undarela11d thal tl1e'res,i11s of this lo sting will be reviewed iiiid ffiai il10 company Wilrternilnale the appllcallon process If the resulls Indicate tho presence of Illegal or Improperly used prescrtpllon drugs In my system.

5, l understand thal should I be hired I will be subjecl lo future substance tesllng, consistent with DOT 49 CFR Part 199,382 and Part 40.

App!loant Nome (Pt1nl) ______________________ _

ApplloanlSlgnalure _______________________ _

_ _ _ _ __ .. _s_o�l_al_s_ecuJity _l'l_un1Mr ____ -.. -.. -... -.. -... -... -.. _-__ -.. -.... -_-___ -___ Dalo __ .-.. -.. --.-----.. -.-.. -.. -... -.. ------. _-_-_ ···-·-··

Eligible for Employmenl Yes __ No __

DRIVER INFORMATION SHEET

POST ACCIDENT TESTING

Post accident drng and alcohol testing is defined in two separate places in regulations. First, a driver must be drng and alcohol tested following an accident if: i

" .. ,the accident involved the loss ofhwnan life; or ... a citation wider State or local law for a moving traffic violation atislug from the accident ... " ls issued. This is found in 49 C.F.R. Part 40, Section 382.303.

' The second portion of the testing crl_ieria is found in Section 390.5 whero a reportable accident is defined as:

"(i) A fatality; (ii) bodily injury lo a person who, as a result of tho injury, Immediately receives medical treatment away fr.om the scene of tho accident; or (iii) One or more veWcles

-- --- ---------- ---- --- ---·incurring disnbling·dnmage as·a res11tt·of the·accideut;requirlllg 1he·veWcle·to·be-transported·away- ----- - - ---from the scene by a tow trnck or other veWcle."

However, in addition to the standards for DOT mandated testing, it is the policy of this company to administer post-accident drug and alcohol testing in the case of m1y accident resulting in property damage or bodily injmy to any party.

A driver should never leave the scene of an accident except as necessary to su1nn1on assistance. The driver must be tested for alcohol within two hours and for drngs within eight hours following an accident. A driver should not use �Icohol following an accident until tested or eight hours have passed since the �ccident. If a driver is unable to provide a specinlen for testing because it would

____ �ihterfere with treatment or if an evidential breath testing device is not available,_a_ release should be signed giving the treatment facility permission to provide results of any testing they have done as a part of the treatment.

THINK TWICE

A)cohol use; possession and distribution is prohibited in the workplace,Consequently, a driver should think twice about over-the-counter medicationitems such as mouthwash before having them on hand. If the solution containsalcohol, and many do, having them in the trnck would be a violation of federallaw. There are many mouthwashes and cold remedies that do not contain alcohol._Be sure to purchase the non-alcoholic items to have with you while on duty.

Remember, a Breath Alcohol Concentration (BrAC) of 0.02-0,039 means a driver would have to be taken off duty for a mininmm of24 hours. A BrAC of 0.04. or greater results in a driver being disciplined up to and including discharge.

COMBINED DISCLOSURE NOTICE AND AUTHORIZATION

REGARDING BACKGROUND CONSUMER REPORTS

IMPOl\'l'ANT1 I'ltnse rco1l cnl'90•11v hof91·• signing,

A cons11111er repoti nndlol' illvosllgativo consumer repo11 Including lnformal!on concetnhtg your charaete,, e111ploymcnt history, 11onorol repulnllon, personol charnelorlstles, polleo record, ednenllo11, (IIIAllllenllons, mo101· veltloloreeord, modo or llvlng nud/or credfr nud Indebtedness may bo obrnhtcd In co1mccllo11 wUh yonrnppllcntlon for mtd/or conlinued employment wllh rho employer, A eoJ1s1rnic1• 1·01101·t nud/01• nu luvosllgnrlvo ,ons1111101· report nmy be ob!nlned nt any !lme dm·lng the appllcntlou 1u·oe<ss OI' <lul'IUg yom· em11loy111ent with tho om1iloyo1·, A cousumc1· NJlort contnining h�ury nnd Illness 1'00ords 1111d medlonl lnformnllon mny be oblalnerl nfiorn lon!nllve offer of 0111plo)'menl hns been mnde, Upnn timely 1vrillen reqnosf of the imsonnol do1m11me111 of !he employ-0r, and wl!hln S days of (lie request, the 11mt10, address and phone number of Ille roporllng ngoney nnd the unlure and scope ofllte lnves!lgalive co11siu11e1· ,�port wlll be disclosed 10 yon,

Bofor,i"•fii nuvil,se rietloil Is fakei,; linseil hi 1vliole <.it· l1i· pnii oii tlio ·1,ifoi111,iil�n-00·11i�iued fo ·u;e eorisu;n;,:,-�;;.;,; )'Oll will be provided a copy of tho rop01t, !he nnmo, nddro,s nnd telephone munber uf !ho repo1lf11g ogeney, mid n sm11m�ry of your rlgl1is under tho Pair Credi! Repotllng Ael,

AUTHOlllZATION

Yon hereby attlhorlzo nnd requosl, wilhoul cny �wva!ion, any preseut or former employe1·, school, polleo dopnrlment, lln•nelal lnsllhtflon, division of 1110!01' vehleles, 0011,11111e1· 1·eporti11g agencies, 01· other persons or ngene!e,1 bavh1g lmowledgo nbout yo1, lo n,rnlsh Firs! Advantigo with any nnd all background htfo.-ntnll❖n In !heh· possession •�gnrdlng you, In order thnl yo111•0111ploymenl q1mll0¢ntlons may bnvnhmted,

READ, ACKNOWLEDGED AND AU'tflORJZJl))

. . . .. . Sl!\11".IUro. . .. . Dn!O- ... ____________________________________________ __________________________________

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt. Number City or Town State ZIP Code

Date of Birth (mm/dd/yyyy) U.S. Social Security Number

- -

Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form W-4 (2018)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply.• For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate▶ Whether you’re entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20181 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name differs from that shown on your social security card,

check here. You must call 800-772-1213 for a replacement card. ▶

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7

Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2018)

9/19/2011

I:30258

Lighthouse Environmental Services, Inc.

Direct Deposit Form Name: ____________________________________________________________________

Email address:______________________________________________________________

Bank Name: _______________________________________________________________

Routing #: ________________________________________________________________ This will be a 9-digit number on the left side of the check – see SAMPLE below.

Account #: _______________________________________________________________

Checking Savings

Please attach a VOIDED check below: This can be a copy of a voided check

Routing Number

9 Digit Number surrounded by I:

Checking Account Number

******************************* If you do not wish to have your check direct deposit, we will mail your check via postal services

unless other arrangements have been made.

It will not be hand delivered to you by your Supervisor / Project Manager. You are responsible for picking up your own check.

*************************************

___________________________________________ _________________________________ Employee Signature Date

P.O. Box 84152 * Pearland, TX 77584 * Ph (713) 987-0400 * Fax (713) 987-0410

SAMPLE NAME HERE 00123 12345 MAIN ANYWHERE, USA 12345 DATE ___________ Pay to the

Order of ____________________________________________ $ ______________________________________________________ DOLLARS BANK NAME

For ___________________________ _____________________

II 000003

I I

I: 051400345

I:

I: 302586789

ii) The presence of a prohibited substance that affects an individual in any detectablemanner. The symptoms of influence may be, but are not limited to, slurred speech ordifficulty in maintaining balance.

f) Contrabandi) Any drug or alcohol related paraphernalia used or designed for use in testing, packaging,

storing, injecting, ingesting, inhaling or otherwise introducing into the human body anyProhibited Substance, or

ii) Any paraphernalia or substance used or designed for use to dilute, substitute, or adulterateany alcohol or drug test specimen, or to otherwise obstruct the alcohol or drug testingprocess or

iii) Firearms, ammunition, explosives, and weapons

g) Designated Employee Representative (DER)Company personnel with oversight of the company Drug and Alcohol program and authorizedby the company to receive test results and make required decisions regarding test results.

h) DisqualifiedCompany personnel are disqualified from performing work if they fail to meet or comply with,or in any way violate this policy and policy of customers.

i) Stand DownThe immediate removal of company personnel from performing services for company and /orcustomers.

j) Medical Review Officer (MRO)A licensed or certified physician, designated by the company, responsible for the review andverification of the integrity of drug testing results and for the final interpretation and reporting ofdrug test results.

k) Prescription DrugA regulated pharmaceutical medicine that requires physician or other qualified healthcareprofessional authorization before it can be obtained in the jurisdiction where companypersonnel are performing services for company or customers. The term is used to distinguish itfrom over-the-counter drugs, which can be obtained without authorization

I) Safety Sensitive PositionsAny position with job responsibilities such that a lapse by an individual in that position couldincrease the probability of serious injury, significant environmental or community impacts orsignificant damage to company or customer assets.

3) PROHIBITIONS

Unless specifically authorized in writing by the company and its customers,LIGHTHOUSE ENVIRONMENTAL SERVICES INC. policy shall prohibit company personnel fromthe following:

a) Using, possessing, selling, manufacturing, distributing, concealing or transporting on companyor customer property (including off-duty time) any of the following items:

i) Any prohibited substance; or

ii) Contraband (except where in violation of state law); or

iii) Being under the influence of any Prohibited Substance.

b) Possessing or using prescription drugs or over-the-counter medication that may causeimpairment, except when a// of the following conditions have been met, while on companyproperty (unless otherwise provided for under the American's with Disabilities Act):

i) Prescription drugs have been prescribed by a licensed physician for the person inpossession of the drugs, and;

ii) The prescription is not expired and was filled by a licensed pharmacist for the personpossessing the drugs, and;

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iii) The individual notifies their supervisor that they will be in possession of, or using,impairment-causing prescription drugs or over-the-counter medication and appropriatesteps are taken to accommodate the possibility of impairment, including but not limited to,removal from work for the period of possible impairment.

Note: Discussions between the individual and their supervisor must be limited to theindividual's ability to perform essential job functions.

iv) Company's health professional has assessed the capability or fitness of personnel toperform safety sensitive duties.

c) Being under the influence of prohibited substances while performing any services for thecompany or their customers.

d) Switching, diluting or adulterating any urine, blood or other sample used for testing.

e) Refusing to submit to a test for alcohol or drugs.

f) Refusing to submit to an inspection as provided for in Section 5 of this Policy.

g) Being the subject of a confirmed positive alcohol or drug test.

4) ROLES AND RESPONSIBILITIES

a) Designated Employee Representative (DER)

Designated Employee Representative (DER) should be an employee within the Health, Safety,Security and Environment (HSSE) department who is authorized to receive test results andother communications, take immediate action to remove workers from a company orcustomer's jobsite and make required decisions in the testing and evaluation process.Specific roles and responsibilities assigned to a DER should include, at a minimum, thefollowing:

i) Select and contract with a laboratory or service provider, based on pre-determined criteria,to help implement all or part of the Drug, Alcohol and Contraband Program.

ii) Receive general correspondence, newsletter, and announcements from laboratories andservice providers.

iii) Coordinate reasonable suspicion training for all supervisors and ensure they have signed adocument acknowledging completion of the training.

iv) Schedule and coordinate drug and alcohol testing activities.

v) Maintain confidential files for the Drug, Alcohol and Contraband Program.

vi) Monitor non-negative, positive, or invalid test results and results supporting that thespecimens have been adulterated or substituted to determine appropriate actions.

b) Medical Review Officer (MRO)

An MRO is responsible for receiving and reviewing laboratory test results and evaluatingmedical explanations for certain drug test results. Roles and responsibilities assigned to anMRO typically include the following:

i) Serve as an independent party to oversee the accuracy and integrity of the company Drugand Alcohol Testing process (DOT and NON-DOT).

ii) Review appropriate copies of chain-of-custody forms to determine if problems exist.

iii) Conduct verification interviews with workers for non-negative drug test results or resultsindicating that the specimen has been adulterated or substituted.

iv) Interpret drug test results to determine if a legitimate medical explanation exists for alaboratory's confirmed positive, an invalid test result or adulterated or substitutedspecimen.

v) Immediately report verified positive or invalid results, results requiring immediate collectionunder direct observation, adulterated or substituted specimens, and other refusals to testto appropriate personnel.

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vi) Report written drug test results in a confidential manner to appropriate personnelauthorized to receive such information

5) SEARCHES AND INSPECTIONS

Searches and inspections may be:

a) Conducted on company or customer property, at any time, by company or customersupervisors or authorized search and inspection specialists including scent trainedanimals.

b) Unannounced searches or inspections of company or customer personnel and theirproperty, which may include, but is not limited to: wallets, purses, lockers, baggage,offices, desks, toolboxes, clothing and vehicles.

c) Employees have the right to refuse being searched or having their personal effectssearched or to cooperate in the requested tests; however, refusal to allow such searchesor to cooperate in such lawfully permitted searches by any employee will be cause fordisciplinary action, up to and including immediate termination.

d) If discovery of Prohibited Substances or Contraband cannot be directly associated withindividual company personnel, but can be reasonably associated with a defined group ofcompany personnel (e.g. people who use one change room):

a. Customers may conduct or require company to conduct an inspection of companypersonnel group's clothing, wallets, purses, baggage, lockers, work areas, desks,tool boxes, vehicles and any other designations by customers, and/or

b. Customers may require company to conduct Group suspicion-based testing ofcompany personnel within this group.

6) TESTING REQUIREMENTS

Drug and alcohol testing must meet the requirements of customers:

a) Pre-Access Testing

i) All company personnel are subject to customer pre-access testing which may mandatethat the employee(s) receive a negative result on a drug and/or alcohol test within acustomer's specific required amount of time preceding the employee's first access tocustomer property. Note: Some customers may waive this requirement if employee(s) arecurrently active in a random testing pool. Annual drug and alcohol testing is also requiredby specific customers. Upon customer's request, company shall so certify in writing.

ii) Company will provide no information to customers identifying individuals who have positivepre-access tests.

b) Post-Incident Testing

Retaliation against employees who report accidents is strictly forbidden. Any drug and alcoholtesting under this section will be applied in a neutral fashion, to foster a safe work environment,and only to identify drug/alcohol use in the recent past. Testing under this section will not beundertaken to retaliate against employees for reporting workplace injuries.

Immediately following an incident or as soon as possible: company should communicate with thecustomer and receive confirmation that post-incident drug and/or alcohol testing will be required.

i) Company shall remove individuals from customer property and surrender their sitecredentials to the customers IF ii is determined by the company or customers, from thebest information available immediately following a work-related incident, that theperformance of one or more company personnel contributed to the incident or cannot becompletely discounted as a contributing factor to the incident

NCMS model: Revised March 2017 6

ii) Alcohol and drug testing must be completed as soon as possible after the decision to test.If specimen collection is not completed within 2 hours, the reason for delay must bedocumented. Customers may request to review reasons for the delay and decide if theyare acceptable. An individual so removed will be allowed to return to work on customerproperty only after.

(1) company conducts alcohol and drug testing on the individual as soon as possiblefollowing the individual's removal from the site, and

(2) the company certifies all of the following in writing:

(a) the test identification number

(b) the individual's 4 digit identifying number

(c) the test date and time, and

( d) a negative test result

(3) On the written certification the company will include a consent signed by the individualpermitting disclosure to customers of the test result.

iii) If an employee who is subject to post-incident testing is conscious, able to urinate normally(in the opinion of a medical professional) and refuses to be tested, that employee shall beremoved from their position and shall be subject to discipline.

For the purpose of this part "incident" means:

(1) An actual event that caused:

(a) Injury requiring medical treatment beyond first aid

(b) Environmental impact beyond a small immediate area to:

(i) soil/ground-water

(ii) marine life, or

(iii) impact to nearby habitat, wildlife, livestock, crops or fisheries

(c) Process Safety events as determined by the responsible company or customerSupervisor

(d) Property damage as determined by the responsible company or customerSupervisor

(e) Motor vehicle accident (the operator of the vehicle or other individuals where thereis evidence to support that they may have contributed to the incident)

****NOTE: Customers may define more stringent criteria

Or

(f) An event that had potential for

(i) Serious injury/fatality

(ii) Environmental impact beyond Company or Customer Premises

(iii) Property damage as determined by the responsible Company or CustomerSupervisor

(2) The Company may decide not to conduct a post-incident drug and/or alcohol test if:

(a) The best information immediately available after the incident indicates that theemployee's performance could not have contributed to the incident, or

(b) Because of the time between the performance and the incident, it is not likely that adrug and/or alcohol test would reveal whether performance was affected by drugand/or alcohol use.

NCMS model: Revised March 2017 7

c) Reasonable Suspicion Testing

i) Upon reasonable suspicion of company or customers that company personnel is under theinfluence of a prohibited substance while on company or customer property (refer toAttachment 3 as a guide to assess whether there is reasonable suspicion for requesting atest), company shall remove the individual(s) from customer property and surrender theirsite credentials to the customers. Company should conduct alcohol and drug testing on theindividual as soon as possible following the individual's removal from the site. If specimencollection is not completed within 2 hours, the reason for delay must be documented.Customers may request to review reasons for delay and decide if they are acceptable

ii) An individual removed from company or customer property for Reasonable Suspicion willbe allowed to return to work on customer property only after:

(1) Company certifies all of the following in writing:

(a) the test identification number

(b) the ,individual's 4 digit identifying number

(c) the test date and time, and

(d) a negative test result

(2) On that written certification the company will include a consent signed by the individualpermitting disclosure to customers of the test result.

d) Group Suspicion-based Testing

i. Group Suspicion-based testing of company personnel may be required without notice oncustomer premises, based on evidence of Prohibited Substances or Contraband oncustomer premises that cannot be identified to a specific individual. Group Suspicion­based testing will be limited to the likely affected work group or work area.

ii. Company will immediately Stand Down the company personnel

iii. Alcohol and drug testing specimen collection must be completed as soon as possible afterthe decision to test. If specimen collection is not completed within 2 hours, the reason fordelay must be documented. Customers may request to review reasons for delay anddecide if they are acceptable.

e) Random Testing

If specific customers require random drug and/or alcohol testing then the following guidelineswill be followed:

i) Unless otherwise specified by a specific customer, company personnel shall be subject to:

(1) Un-announced random testing

(2) Performed on a quarterly basis (at a minimum). Random tests must not be predictable.

(3) That yields a compliance of an annualized rate as determined by the customeroperator

ii) If required by the specific customer, a breath alcohol test will be given at the same time asthe drug test.

iii) Upon notification of being selected for a drug and/or alcohol test, company personnel mustreport to the collection site within 30 minutes, plus travel time. The reason for delay mustbe documented if unable to arrive within this time frame

iv) Failure to report to the collection site, refusal to test, or adulterating a specimen isconsidered the same as a positive test and the individual could be denied access tocompany or customer premises.

v) If company personnel are not in the random pool when a random selection is made, theymust complete another pre-enrollment test before being re-admitted to the random pool.

NCMS model: Revised March 2017 8

iv) Quality-Control procedures must be:

(1) written and available, and

(2) include testing blank and spiked samples for verification

v) Laboratories must be able to provide technical assistance and advice concerning drug andalcohol testing.

vi) Sample supplies appropriate to the type of specimen being collected or the test run mustbe readily available from the laboratory.

vii) Laboratories must be able to generate confidential and accurate reports.

c) Collection Personnel

i) Urine specimens must be collected by personnel who have been trained and certifiedaccording to the SAMHSNDHHS guidelines which includes:

(1) basic information,

(2) qualification training,

(3) initial proficiency demonstration,

(4) refresher training, and

(5) error correction training

ii) Hair follicle specimens must be collected by personnel that have documentation supportingthat they have been trained in:

(1) equipment and procedures used in gathering and collecting hair follicle specimens

(2) preparing chain-of-custody forms

(3) preparing the specimen for shipment, and

(4) shipping the sample to an approved laboratory.

Note: Hair testing will only be utilized for customer compliance when the customer hasauthorized this testing method

iii) Breath/Saliva testing shall be conducted utilizing devices approved by the NationalHighway Traffic Safety Administration or equivalent. All collection and testing proceduresshall mirror as closely as possible to US DOT (Department of Transportation) protocols.

d) Alcohol

Personnel that have a blood alcohol concentration (BAG) level:

i) Personnel that have a blood alcohol concentration (BAG) level equal to or greater than0.02 during pre-employment confirmation testing are considered to be under the influenceof alcohol and will not be eligible to perform services for certain customers.

ii) Personnel that have a blood alcohol concentration (BAG) level equal to 0.02 and less than0.04 must be removed from performing safety or security-sensitive activities until the BAGlevel is below 0.02 (unless customer specifies a more stringent level) and until 8 hourshave elapsed.

iii) Personnel that have a blood alcohol concentration (BAG) level equal to or greater than0.04 have violated the Drug, Alcohol and Contraband Program and are subject todisciplinary action up to and including termination (unless customer specifies a morestringent level).

8) NON-COMPLIANCE

Company personnel will be found to be in non-compliance if they: • Violate any portion of this policy or the customer's policy, or

• Refuse to cooperate with the searches and tests included in this policy or thecustomer's policy

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9) DISQUALIFIED COMPANY PERSONNEL

With respect to company personnel that are disqualified from performing services forcustomers:

• Company shall immediately remove the individual from customer property

• Company shall immediately notify the customer that the individual is disqualified fromperforming services

• Company will not assign or reassign the disqualified individual to perform services forthe customer or in any other facility of the customer in the future.

• Company will immediately review with customer the nature of the work previouslyperformed by the individual.

• At customer's request, company shall, at its sole cost and risk, inspect all work in whichthe individual may have participated and submit a written report to the customer thatdocuments the inspection and any findings and the actions taken to assure alldeficiencies have been corrected.

"Note: (Company shall comply with all applicable state and local related laws. If restrictions are placed on employers, who have individuals that violate this policy, company shall contact their customer representative for instructions pertaining to the specific individual.)

10) SUBSTANCE ABUSE AWARENESS

Company warrants that company personnel performing work have each been fully informedof the requirements of this policy and customer's policy. Before beginning work on companyor customer property, all company personnel must sign a written certification that they havebeen so informed and agree to be bound by the requirements. See Attachment 1.

11) APPLICABLE LAWS

Company shall comply with all applicable Federal, State, and local drug and alcohol relatedlaws and regulations applicable to company personnel (e.g., DOT regulations, Department ofDefense (DOD) Drug-Free Workplace Policy, Drug-Free Workplace Act of 1988, etc.).

12) SUPERVIS0R TRAINING

Company shall provide training/education to company supervisors. The list, at a minimum,should consist of:

• Recognition of performance indicators of probable drug and/or alcohol use

• Effects and consequences of drug and/or alcohol use to personal health, safety and theworkplace

• 60-minute training session on the specific, contemporaneous, physical, behavioral, andperformance indicators of probable drug use.

• 60-minute training session on the specific, contemporaneous, physical, behavioral, andperformance indicators of probable alcohol use.

• Random testing notification process

• Post-incident testing process

• Stand-down process

• Disqualified individual processes, which includes flagging those individuals to ensure theywon't be sent back to work for a customer.

** Records of trained individuals (including name and date) must be maintained by the company and available to customers upon request. See Attachment 3

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