1. a) The name and address of the applicant;

2. b) Identification of each waste disposal site at any time owned or operated by the applicant, or at which the applicant served as chief operator, including:

   1. 1) The name and address of each site; and
   2. 2) A description of the nature of each site and the type of waste disposed there (e.g., hazardous waste, municipal waste); and
   3. 3) A description of the length of and nature of involvement with each site;

3. c) A copy of any final administrative or judicial determination, made after opportunity for an adversarial proceeding, that the applicant has:

   1. 1) Violated federal, state or local laws, regulations or ordinances governing the operation of any waste disposal site;
   2. 2) Been convicted in Illinois or another state of any crime which is a felony under Illinois law, or been convicted of a felony in a federal court;
   3. 3) Shown gross carelessness or incompetence in the handling, storing, processing, transporting or disposing of any hazardous waste in any state;

4. d) A description, including the name of the agency or court, title, docket number and status, of any administrative or judicial proceeding, which is still pending, which:

   1. 1) Could result in a determination against the application of type described in subsection (c); or
   2. 2) Could result in a reversal of any administrative or judicial determination provided by the applicant in response to subsection (c);
5. e) An affidavit attesting to the truth and completeness of the facts asserted in the application.

An application for prior conduct certification shall include: