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Brief history of the source property, including all property uses:

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 xxxx. 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: