Name (required):

City (required):

State, Zip (required):

County:

Contact:

Email (required):

Phone (required):

Fax:

Signature (required):

Name (required):

City (required):

State, Zip (required):

County:

Contact:

Email (required):

Phone (required):

Fax:

Signature (required):

Name:

City:

State, Zip:

County:

Contact:

Email:

Phone:

Fax:

Truck Type: End Dump Semi-Bottom Double Bottom 10 Wheeler Super 10 Transfer

Description (required):

Type of Facility (required): Residential Commercial Industrial Agricultural

Site History (required): Residential Commercial Industrial Agricultural

Type of Fill (ie Excavation, Road Replacement, Basement; required):

Total Quantity (required): Cubic Yards Tons Loads

Status (required): Stockpile In Situ

Proposed Start (required):

Is this a USEPA (40 CFR Part 261) State Hazardous Waste? (response required)
Yes    No

Is the waste from a Federal (40 CFR 300, App B) or state mandated clean-up? (response required)
Yes    No

Does the waste contain any radioactive material or TSCA regulated concentrations of PCBs? (response required)
Yes    No

Does the waste contain untreated, regulated, medical or infectious waste? (response required)
Yes    No

Does the waste contain Asbestos? (response required)
Yes    No

Does the waste contain more than 5% over optimum moisture? (response required)
Yes    No