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Has the source property ever been known or suspected to be contaminated?_____
Do historical operations at the property reflect or suggest the potential for radiological contaminants? _____
Are there naturally occurring radiological materials known or suspected at the source property? _____
If applicable, the date soil/fill material was subject to analytical testing (provide copies): _____
If analytical results are not provided, justification for determining the soil/fill is acceptable without the need for analytical results: _____
I, the undersigned, certify under penalty of law, that the information provided in Parts 1 and 2 of this form is true and correct to the best of my knowledge and that the soil/fill material meets the definition of acceptable soil/fill as identified in Chapter xxxxx. I also certify, based upon visual inspection, that the soil material does not contain solid waste, any free liquid other than water, obvious signs of staining or discoloration, and that it will not create a public nuisance such as, but not limited to, odors.
Signature:_____
Part 3: Person receiving or placing acceptable soil/fill material
Date:
Name (print): ___ Title: ___
Company Name: _____
Street Address: ___
City: _____ State: _____ Zip: _____
Phone #:_____ Email Address:_____
Physical address of soil/fill placement: _____
Block ___ Lot(s) ___
City: _____ State: _____ Zip: _____