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1 <br /> GENERATOR AFFIDAVIT,CERTIFICATION AND INDEMNIFICATION <br /> STATEMENT <br /> The undersigned Affiant certifies that the information contained in and attached to this profile <br /> is accurate and complete to the best of his/her knowledge,that fill materials to be delivered to this <br /> Aggregate Industries site are clean and inert and that there are no known materials that would <br /> significantly affect the inert nature of the fill materials,nor are there any acid forming materials <br /> or toxic producing materials in said fill materials. Furthermore,by signing this Statement,the <br /> undersigned shall,to the extent permitted by law,indemnify and hold harmless Aggregate <br /> Industries in the event it should be determined that any material provided to Aggregate Industries <br /> is contaminated with any regulated pollutant and/or poses environmental harm. The undersigned <br /> shall,to the extent permitted by law,assume all liability and costs <br /> associated with the removal,disposal and negative impacts of any contaminated material <br /> provided to Aggregate Industries. <br /> Signed this day of J a.,rZ ,20 ) 7 . <br /> Name and Company: lBo h J A e r Ce f 7 R r ks s J O p e., !�h c a, <br /> Signature <br /> Title <br /> STATE OF COLORADO ) <br /> pp � )ss. <br /> County of ao uo. ) <br /> Subscribed and sworn to this�_day of tJ UnrE ,201-) by <br /> EaNd S42EwGE, .asIn4,r4,n I V" Of <br /> Or SPIVIC <br /> Witness my hand and official seal. WW WELCH <br /> NOTARY PUBLIC <br /> STATE OF OOLORA00 <br /> WNW I aj M3400 M <br /> W0001488mexpM1Ea FEMgW1Y 1{.sm <br /> (SEAL) & vj[/-� <br /> �► Notary Public <br /> My Commission expires: a/�y/�0,)Q <br /> Aggregate Industries-Inert Fill Materials Profile Form <br /> Page 3 of 3 <br />