Fill and Sign the Pueblo County Marijuana Excise Tax Return County Pueblo Form

Conflict or Bias Disclosure Form Identification Name of Individual or Corporate Entity: Chris Ellison Name of Employer: NIOSH/OCAS Today's Date: 1/11/2007 Sites/Facilities addressed on this form: See Attached Questions to Identify a Conflict or Bias 1. Are you1 currently engaged in any capacity (paid or unpaid) by the U.S. Department of Energy (DOE)? Check Yes or No. “Site” and “facility” are defined to include DOE, AWE and other federally-owned or -operated sites. For purposes of brevity, the "other federally-owned or -operated sites" category shall be referred to in this document as “other” sites. Yes ____, a COB exists and the individual with the COB cannot perform any key Program function for any site. If yes, please provide details about each DOE location (specific site or sites) at which you are currently engaged, a description of your activities for DOE, and whether you are paid or unpaid. Stop. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _________ No ___X____ proceed to Question 2. 2. Do you, or did you, work either at or for this DOE or Atomic Weapons Employer (AWE) site? Check Yes or No. "Work" means employment at or for the site, site contractor or site subcontractor that includes management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site. Yes _______, a COB exists and the individual with the COB cannot perform a key Program function related to this site or sites. Please provide details below about the DOE or AWE site(s) you work/worked at or for. Stop. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No ___X_____, proceed to Question 3. 1 For purposes of completing this form, “you” refers to an individual or an employer (depending on which party is completing the form). 3. Do you, or did you, work for any of the past or current operators of this site? Check Yes or No. "Operator" refers to the governmental and/or corporate entities responsible for performing and overseeing day-to-day activities at the site, and includes work, as defined above, performed by the operator's (sub)contractors Yes _______, provide the names of the past or current operators, the name of the site that the operator did or does administer and the specific times (starting and stopping dates) that you worked, or continue to work, for the operator and proceed to Question 4. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No ____X____, proceed to Question 6. 4. During the time you worked for that operator, was that operator responsible for this site? Check Yes or No. Yes _______, proceed to Question 5. No ________, proceed to Question 6. 5. Did your work for the operator have an impact on this site? Check Yes or No. "Impact" means that your work involved decision-making authority over management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site. Yes _______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide details about the nature of the impact your work for the operator had on the site below. Stop. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No ________, proceed to Question 6. 6. Did you work for DOE in the past? Check Yes or No. "Work for DOE" does not include work, as defined above, for DOE of less than four months’ continuous duration as a student intern, graduate fellow or in another primarily educational capacity. It also does not include having received a financial stipend from DOE for graduate study, a fellowship in the context of an established DOE fellowship program intended to support graduate-level work, or receipt of a federal government retirement pension for prior DOE service. Yes _______, please provide details about each DOE location (specific site or sites) you worked for in the past and a description of your work for DOE (you may use a checklist listing DOE/AWE sites) and then proceed to Question 7. 2 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No _____X_______, proceed to Question 8. 7. Did your work for DOE have an impact on this site? Check Yes or No. "Impact" means that your work involved decision-making authority over management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site. Yes _______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide details below about the nature of the impact your work for the operator had on the site. Stop. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No _____, then proceed to Question 8. 8. Do you have a familial relationship, or a supervisory or subordinate work relationship with an EEOICPA claimant whose claim involves this site? Check Yes or No. “Familial relationship” encompasses a current spouse, child, parent, sibling or grandparent that worked at or for the site; or any survivors a current spouse, child, parent, sibling or grandparent that are eligible to file claims under the Program. “Supervisory or subordinate work relationship” is one where (a) the individuals in question are/were in the same reporting chain and within two organizational levels of one another; and (b) "Work" means employment at or for the site, site contractor or site subcontractor that includes management, direction, or implementation of radiation protection and/or health physics program policies, procedures or practices related to atomic weapons activities at the site. Yes ______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide below details about the nature of your relationship with the EEOICPA claimant. Stop. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No ____X_______, then proceed to Question 9. 3 9. Do you have a familial relationship, or supervisory or subordinate work relationship with anyone who has had an impact related to the site? Check Yes or No. Yes ______, then proceed to Question 10. No ____X____, then proceed to Question 11. 10. If you have a subordinate relationship to someone who has (had) an impact on the site, has a different person been designated to review your job performance as it relates to the site? Check Yes or No. Yes ____, a COB does not exist. Proceed to Question 11. No ______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide more detailed information about your relationship with the person having an impact on the site. Stop. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 11. Do or did you have a familial, financial or non-financial professional (e.g., providing expert advice) relationship with any attorney at the time the attorney represented an EEOICPA claimant, DOE or the operator? Yes _______, then a COB exists and the individual with the COB cannot perform a key Program function for this site or sites. Please provide details about the relationship with the attorney, to include (if applicable) a list of cases for which you assisted the attorney as well as the names of parties on whose behalf you testified or otherwise provided assistance. Stop. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ No ___X_____, then a COB does not exist. 4 Additional Details for Disclosure Questions 1-11 Please specify the number of the question(s) for which you are giving additional details. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 5 Name: Chris Ellison Date: 1/11/2007 Mark an "X" each facility evaluated in the multiple site disclosure form Covered Site City X AC Spark Plug Flint X AMCOT Fort Worth X Aeroprojects, Inc. West Chester X Ajax Magnathermic Corp. Youngstown X Alba Craft Oxford X Albany Research Center Albany X Albuquerque Operations Office Albuquerque X Aliquippa Forge Aliquippa X Allegheny-Ludlum Steel Watervliet X Allied Chemical Corp. Plant Metropolis X Allied Chemical and Dye Corp. North Claymont X Allis-Chalmers Co. West Allis, Milwaukee X Aluminum Co. of America (Alcoa) 1 New Kensington X Aluminum Co. of America (Alcoa) 2 Garwood X Amchitka Island Nuclear Explosion Site Amchitka Island X American Bearing Corp. Indianapolis X American Chain and Cable Co. Bridgeport X American Machine and Foundry Brooklyn X American Machine and Metals, Inc. E. Moline X American Peddinghaus Corp. Moonachle X American Potash & Chemical West Hanover X Ames Laboratory Ames X Anaconda Co. Waterbury X Argonne National Laboratory - East Argonne X Argonne National Laboratory - West Scoville X Armco-Rustless Iron and Steel Baltimore X Armour Fertilizer Works Bartow X Armour Research Foundation Chicago X Arthur D. Little Co. San Francisco X Ashland Oil Tonawanda X Associated Aircraft Tool and Manufacturing Co. Fairfield X B & T Metals Columbus X BONUS Reactor Plant Punta Higuera X BWXT Lynchburg X Baker Brothers Toledo X Baker and Company Newark X Baker and Williams Warehouses New York X Baker-Perkins Co. Saginaw X Battelle Laboratories - King Avenue Columbus X Battelle Laboratories - West Jefferson Columbus X Bell Telephone Laboratories Murray Hill X Bendix Aviation (Pioneer Division) Davenport X Beryllium Production Plant (Brush) Luckey X Besley-Wells South Beloit X Bethlehem Steel Lackawanna X Birdsboro Steel & Foundry Birdsboro X Bliss & Laughlin Steel Buffalo X Blockson Chemical Co. (Building 55 and related activities) Joliet X Bloomfield Tool Co. Bloomfield State MI TX PA OH OH OR NM PA NY IL DE WI PA NJ AK IN CT NY IL NJ MA IA CT IL ID MD FL IL CA NY OH OH PR VA OH NJ NY MI OH OH NJ IA OH WI NY PA NY IL NJ Name: Chris Ellison Date: 1/11/2007 Mark an "X" each facility evaluated in the multiple site disclosure form Covered Site City X Bowen Engineering, Inc. North Branch X Bridgeport Brass Co., Adrian Adrian X Bridgeport Brass Co., Havens Lab Bridgeport X Brookhaven National Laboratory Upton X Brush Beryllium Co. 1 Detroit X Brush Beryllium Co. 4 Cleveland X C - B Tool Products Co. Chicago X C. G. Sargent & Sons Graniteville X C. H. Schnorr Springdale X C. I. Hayes, Inc. Cranston X California Research Corp. Richmond X Callite Tungsten Co. Union City X Carboloy Co. Detroit X Carnegie Institute of Technology Pittsburgh X Carpenter Steel Co. Reading X Chambersburg Engineering Co. Chambersburg X Chapman Valve Indian Orchard X Chemical Construction Co. Linden X Chupadera Mesa Chupadera Mesa X Cincinnati Milling Machine Co. Cincinnati X Clarksville Facility Clarksville X Colonie Site (National Lead) Colonie (Albany) X SAM Laboratories, Columbia University New York City X Combustion Engineering Windsor X Connecticut Aircraft Nuclear Engine Laboratory Middletown X Copperweld Steel Warren X Crane Co. Chicago X Crucible Steel Co. Syracuse X Dana Heavy Water Plant Dana X Dorr Corp. Stamford X Dow Chemical Co. Walnut Creek X Du Pont - Grasselli Research Laboratory Cleveland X Du Pont Deepwater Works Deepwater X ERA Tool and Engineering Co. Chicago X Edgerton Germeshausen & Grier, Inc. Boston X Electro Circuits, Inc. Pasadena X Electro Metallurgical Niagara Falls X Elk River Reactor Elk River X Area IV of the Santa Susana Field Laboratory Santa Susana X Environmental Measurements Laboratory New York X Extruded Metals Co. Grand Rapids X Extrusion Plant (Reactive Metals Inc.) Ashtabula X Feed Materials Production Center (FMPC) Fernald X Fenn Machinery Co. Hartford X Fenwal, Inc. Ashland X Fermi National Accelerator Laboratory Batavia X Foote Mineral Co. East Whiteland Twp. X GSA 39th Street Warehouse Chicago X Gardinier, Inc. Tampa State NJ MI CT NY MI OH IL MA PA RI CA NJ MI PA PA PA MA NJ NM OH TN NY NY CT CT OH IL NY IN CT CA OH NJ IL MA CA NY MN CA NY MI OH OH CT MA IL PA IL FL Name: Chris Ellison Date: 1/11/2007 Mark an "X" each facility evaluated in the multiple site disclosure form Covered Site City X General Atomics La Jolla X General Electric Company Cincinnati / Evendale X General Electric Plant Shelbyville X General Electric Vallecitos Pleasanton X Grand Junction Operations Office Grand Junction X General Steel Industries Granite City X Great Lakes Carbon Corp. Chicago X Gruen Watch Norwood X Hallam Sodium Graphite Reactor Hallam X Hanford Richland X Harshaw Chemical Co. Cleveland X Heald Machine Co. Worcester X Heppenstall Co. Pittsburgh X Herring - Hall Marvin Safe Co. Hamilton X Hooker Electrochemical Niagara Falls X Horizons, Inc. Cleveland X Hunter Douglas Aluminum Corp. Riverside X Huntington Pilot Plant Huntington X Idaho National Laboratory Scoville X International Minerals and Chemical Corp. Mulberry X International Nickel Co., Bayonne Laboratories Bayonne X International Rare Metals Refinery, Inc. Mt. Kisco X International Register Chicago X Iowa Ordnance Plant Burlington X Ithaca Gun Co. Ithaca X J. T. Baker Chemical Co. Phillipsburg X Jessop Steel Co. Washington X Joslyn Manufacturing and Supply Co. Ft. Wayne X Kaiser Aluminum Corp. Dalton X Kansas City Plant Kansas City X Kauai Test Facility Kauai X Kellex/Pierpont Jersey City X Kerr - McGee Guthrie X Koppers Co., Inc. Verona X La Pointe Machine and Tool Co. Hudson X LaCrosse Boiling Water Reactor LaCrosse X Laboratory for Energy-Related Health Research Davis X Laboratory of Biomedical and Environmental Sciences Los Angeles X Laboratory of Radiobiology and Environmental Health San Francisco X Lake Ontario Ordnance Works Niagara Falls X Landis Machine Tool Co. Waynesboro X Latty Avenue Properties Hazelwood X Lawrence Berkeley National Laboratory Berkeley X Lawrence Livermore National Laboratory Livermore X Linde Air Products Buffalo X Linde Ceramics Plant Tonawanda X Lindsay Light and Chemical Co. W. Chicago X Los Alamos Medical Center Los Alamos X Los Alamos National Laboratory Los Alamos State CA OH IN CA CO IL IL OH NE WA OH MA PA OH NY OH CA WV ID FL NJ NY IL IA NY NJ PA IN IL MO HI NJ OK PA MA WI CA CA CA NY PA MO CA CA NY NY IL NM NM Name: Chris Ellison Date: 1/11/2007 Mark an "X" each facility evaluated in the multiple site disclosure form Covered Site City X Lovelace Respiratory Research Institute Albuquerque X DOW Chemical Co. (Madison Site) Madison X Magnus Brass Co. Cincinnati X Mallinckrodt Chemical Co., Destrehan St. Plant St. Louis X Massachusetts Institute of Technology Cambridge X Mathieson Chemical Co. Pasadena X Maywood Chemical Works Maywood X McKinney Tool and Manufacturing Co. Cleveland X Medart Co. St. Louis X Medina Facility San Antonio X Metals and Controls Corp Attleboro X Middlesex Municipal Landfill Middlesex X Middlesex Sampling Plant Middlesex X Midwest Manufacturing Co. Galesburg X Mitchell Steel Co. Cincinnati X Mitts & Merrel Co. Saginaw X Monsanto Chemical Co. Dayton X Mound Plant Miamisburg X Museum of Science and Industry Chicago X National Bureau of Standards, Van Ness Street Washington X National Guard Armory Chicago X National Research Corp. Cambridge X Naval Research Laboratory Washington X Nevada Test Site Mercury X New Brunswick Laboratory New Brunswick X New England Lime Co. Canaan X New York University New York X Norton Co. Worcester X Nuclear Materials and Equipment (NUMEC) - Parks Township Parks Township X Nuclear Materials and Equipment Corp. (NUMEC) - Apollo Apollo X Nuclear Metals, Inc. Concord X Oak Ridge Gaseous Diffusion Plant (K-25) Oak Ridge X Oak Ridge Hospital Oak Ridge X Oak Ridge Institute for Science Education Oak Ridge X Oak Ridge National Laboratory (X-10) Oak Ridge X Oliver Corp. Battle Creek X Pacific Northwest National Laboratory Richland X Pacific Proving Ground Marshall Islands X Paducah Gaseous Diffusion Plant Paducah X Painsville Site (Diamond Magnesium Co.) Painsville X Pantex Plant Amarillo X Peek Street Facility Schenectady X Penn Salt Co. Philadelphia / Wyndmoor X Philadelphia Naval Yard Philadelphia X Pinellas Plant Clearwater X Piqua Organic Moderated Reactor Piqua X Podbeliniac Corp. Chicago X Portsmouth Gaseous Diffusion Plant Piketon X Precision Extrusion Co. Bensenville State NM IL OH MO MA TX NJ OH MO TX MA NJ NJ IL OH MI OH OH IL DC IL MA DC NV NJ CT NY MA PA PA MA TN TN TN TN MI WA MH KY OH TX NY PA PA FL OH IL OH IL Name: Chris Ellison Date: 1/11/2007 Mark an "X" each facility evaluated in the multiple site disclosure form Covered Site City X Princeton Plasma Physics Laboratory Princeton X Project Chariot Site Cape Thompson X Project Faultless Nuclear Explosion Site Central Nevada Test Site X Project Gasbuggy Nuclear Explosion Site Farmington X Project Gnome Nuclear explosion Site Carlsbad X Project Rio Blanco Nuclear Explosion Site Rifle X Project Rulison Nuclear Explosion Site Grand Valley X Project Shoal Nuclear Explosion Site Fallon X Puerto Rico Nuclear Center Mayaguez X Purdue University Lafayette X Quality Hardware and Machine Co. Chicago X R. Krasburg and Sons Manufacturing Co. Chicago X R. W. Leblond Machine Tool Co. Cincinnati X Radium Chemical Co. New York X Rare Earth/W. R. Grace Wayne X Reed Rolled Thread Co. Worcester X Revere Copper and Brass Detroit X Rocky Flats Plant Golden X Roger Iron Co. Joplin X Sacandaga Facility Glenville X Salmon Nuclear Explosion Site Hattiesburg X Sandia Laboratory-Salton Sea Base Imperial County X Sandia National Laboratory Albuquerque X Sandia National Laboratories - Livermore Livermore X Savannah River Site Aiken X Sciaky Brothers, Inc. Chicago X Seaway Industrial Park Tonawanda X Separations Process Research Unit (at Knolls Lab) Schenectady X Seymour Specialty Wire Seymour X Shattuck Chemical Denver X Shippingport Atomic Power Plant Shippingport X Shpack Landfill Norton X Simonds Saw and Steel Co. Lockport X South Albuquerque Works Albuquerque X Southern Research Institute Birmingham X Spencer Chemical Co., Jayhawks Works Pittsburg X Sperry Products, Inc. Danbury X St Louis Airport Storage Site (SLAPS) St. Louis X Standard Oil Development Co. of NJ Linden X Stanford Linear Accelerator Center Palo Alto X Star Cutter Corp. Farmington X Staten Island Warehouse New York X Stauffer Metals, Inc. Richmond X Superior Steel Co. Carnegie X Sutton, Steele and Steele Co. Dallas X Swenson Evaporator Co. Harvey X Sylvania Corning Nuclear Corp - Bayside Laboratories Bayside X Sylvania Corning Nuclear Corp - Hicksville Plant Hicksville X Tech-Art, Inc. Milford State NJ AK NV NM NM CO CO NV PR IN IL IL OH NY NJ MA MI CO MO NY MS CA NM CA SC IL NY NY CT CO PA MA NY NM AL KS CT MO NJ CA MI NY CA PA TX IL NY NY OH Name: Chris Ellison Date: 1/11/2007 Mark an "X" each facility evaluated in the multiple site disclosure form Covered Site City X Tennessee Valley Authority Muscle Shoals X Texas City Chemicals, Inc. Texas City X Thomas Jefferson National Accelerator Facility Newport News X Titanium Alloys Manufacturing Niagara Falls X Titus Metals Waterloo X Tocco Induction Heating Div Cleveland X Torrington Co. Torrington X Trinity Nuclear Explosion Site White Sands Missile Range X Tube Reducing Co. Wallington X Tyson Valley Powder Farm St. Louis X U.S. Steel Co., National Tube Division McKeesport X United Lead Co. Middlesex X United Nuclear Corp. Hematite X University of California Berkeley X Metallurgical Laboratory Chicago X University of Denver Research Institute Denver X University of Florida Gainesville X University of Michigan Ann Arbor X University of Rochester Atomic Energy Project Rochester X University of Virginia Charlottesville X Utica St. Warehouse Buffalo X Ventron Corporation Beverly X Virginia-Carolina Chemical Corp. Nichols X Vitro Corp. of America, Chattanooga Chattanooga X Vitro Corp. of America, West Orange West Orange X Vitro Manufacturing Canonsburg X Vulcan Tool Co. Dayton X W. E. Pratt Manufacturing Co. Joliet X W. R. Grace Erwin X W. R. Grace Co., Agricultural Chemical Div. Ridgewood X W. R. Grace and Company Curtis Bay X Wah Chang Albany X Waste Isolation Pilot Plant Carlsbad X Watertown Arsenal Watertown X Weldon Spring Plant Weldon Spring X West Valley Demonstration Project West Valley X Westinghouse Atomic Power Development Plant East Pittsburgh X Westinghouse Electric Corp. Bloomfield X Winchester Engineering and Analytical Center Winchester X Woburn Landfill Woburn X Wolff - Alport Chemical Corp. Brooklyn X Wolverine Tube Division Detroit X Wyckoff Drawn Steel Co. Chicago X Wykoff Steel Co. Newark X Y-12 Plant Oak Ridge X Yucca Mountain Site Characterization Project Yucca Mountain X Carborundum Company Niagara Falls X Oak Ridge Thermal Diffusion Plant (S-50) Oak Ridge X Westinghouse Nuclear Fuels Division Cheswick State AL TX VA NY IA OH CT NM NJ MO PA NJ MO CA IL CO FL MI NY VA NY MA FL TN NJ PA OH IL TN FL MD OR NM MA MO NY PA NJ MA MA NY MI IL NJ TN NV NY TN PA Name: Chris Ellison Date: 1/11/2007 Mark an "X" each facility evaluated in the multiple site disclosure form Covered Site City X Tonopah Test Site North Las Vegas X Ore Buying Station at Globe Globe X Green Sludge Plant Uraven X Uranium Mill in Durango Durango X Ore Buying Station at Grants Grants X Ore Buying Station at Shiprock Shiprock X Ore Buying Station at Edgemont Edgemont X Ore Buying Station at Marysvale Marysvale X Ore Buying Station at Moab Moab X Ore Buying Station at Monticello Monticello X Ore Buying Station at White Canyon White Canyon X Uranium Mill in Monticello Monticello X Ore Buying Station at Crooks Gap Crooks Gap X Ore Buying Station at Riverton Riverton X General Electric X-Ray Division Milwaukee X Nevada Site Office North Las Vegas X High Energy Rate Forging (HERF) Facility Oxnard X Mill at Moab Utah Moab X Clinton Engineer Works (CEW) Oak Ridge X Canoga Avenue Facility (Vanowen Building) Los Angeles X De Soto Avenue Facility Los Angeles X Downey Facility Los Angeles X Kirtland Operations Office Albuquerque X Ross Aviation Albuquerque State NV AZ CO CO NM NM SD UT UT UT UT UT WY WY WI NV CA UT TN CA CA CA NM NM