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Plan Revision Date: Apol,2029 <br />VIII. Appendix_A Acknowledgement/Receipt Form <br />I acknowledge, by signinq this form, that my full compliance with the Anti -Drug and Alcohol Misuse <br />Prevention Plan the "Plan" and DOT drug and alcohol regulation requirements is a condition of m <br />initial and continued employment with the Company. I understand and agree that I may be discharged <br />or otherwise disciplined for any druq and/or alcohol violation, committed by me, as cited in the Plan and/or <br />in the DOT drug and alcohol regulatory requirements. <br />I also acknowledge, by signing this form that a copy of the Plan has been made available to me and that <br />I have read and understand the requirements of the Company and DOT drug and alcohol program. I have <br />also been provided with informational materials on the dangers and problems of drug abuse and alcohol <br />misuse. <br />Signed, this the day of , 20 <br />Employee Name (Please Print) <br />Employee Signature <br />Premium Concrete Services, Inc.- PHMSA DRUGIALCOHOL PLAN 38 <br />`IATiG:,0tiCCMPLIAI9CE',WA.-IC-F%1ENTSER'V:CENJCi_I1)11oupcnl-,2,121)ThgNCNISplmnis <br />Ihr ,nhlnrr nS a rrniarrarl rnnvonht aril is ri-ti Noll by cnnvnnhr laws in thn I I S and Marvtrhnrn Ali Anhtr <br />