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DLT-L-118 3/2004 STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS RHODE ISLAND DEPARTMENT OF LABOR AND TRAINING DIVISION OF OCCUPATIONAL SAFETY RIGHT - TO - KNOW 1511 PONTIAC AVENUE PO BOX 20157 CRANSTON RI 02920-0942 PHONE 401 462-8570 FAX 401 462-8576 www. dlt. ri. gov/occusafe/righttoknow. htm ANNUAL RENEWAL REGISTRATION In accordance with the Rhode Island General Laws Section 28-21 attached is your annual Hazardous Substance Right-to-Know Registration Form* Complete and return the bottom half by the due date and and retain the top half for your records. YEAR S AMOUNT FEE DUE BY CHECK NO. CUT OFF AND RETAIN FOR YOUR RECORDS Make check or money order payable to RI Department of Labor and Training RTK TYPE OF BUSINESS Business location if different from mailing address PROOF OF TRAINING I the undersigned hereby certify that all employees who are exposed to any hazardous substances have received their annual training as specified in Section 28-21-9 of the Hazardous attach additional pages if necessary. dlt. ri. gov/occusafe/righttoknow. htm ANNUAL RENEWAL REGISTRATION In accordance with the Rhode Island General Laws Section 28-21 attached is your annual Hazardous Substance Right-to-Know Registration Form* Complete and return the bottom half by the due date and and retain the top half for your records. YEAR S AMOUNT FEE DUE BY CHECK NO. CUT OFF AND RETAIN FOR YOUR RECORDS Make check or money order payable to RI Department of Labor and Training RTK TYPE OF BUSINESS Business location if different from mailing address PROOF OF TRAINING I the undersigned hereby certify that all employees who are exposed to any hazardous substances have received their annual training as specified in Section 28-21-9 of the Hazardous attach additional pages if necessary.

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