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SUBSTANCE ABUSE POLICY <br />DOCUMENT NO.: EHS-000146 <br />REV #: 1 <br />Date of Issue: 8/23/2016 <br />Next Rev.: <br />EH&S Procedures <br />Issued By: Corporate Safety Director <br />6/15/2021 <br />Date of Approval: 6/15/2017 <br />Standard Owner: EH&S Department <br />Approved By: Safety <br />NAME: <br />ADDRESS: <br />TELEPHONE: <br />Appendix — A: <br />Uniform Drug and Alcohol Policy <br />Drug and Alcohol Screening Consent Form <br />PLEASE PRINT <br />Last Name First Middle <br />SS# <br />I agree to undergo drug screening by urinalysis and alcohol screening by breath analysis as a condition of <br />working at the Company. <br />I understand and agree that the result of such test will be released to the Company's, Medical Review <br />Officer, the Company's Safety Committee, the Company's Third Party Administrator, or as required by <br />law. Results will be used consistent with the Company's Drug and Alcohol Policy. <br />I understand that if I refuse to consent to testing or the tests show impermissible levels of drugs and/or <br />alcohol. <br />a) I will not be hired, if I am applicant for the Company <br />b) I will be denied access to Company premises. <br />Signature <br />Date <br />Page 13 of 22 <br />