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1. Has the source property ever been known or suspected to be contaminated?_____
2. Do historical operations at the property reflect or suggest the potential for radiological contaminants? _____
3. 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: _____

Certification

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: _____