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AGGREGATE <br /> INDUSTRIES <br /> EXHBIT C —INERT FILL MATERIALS PROFILE FORM <br /> DRMS Permit M-XXX-YYY—MINE NAME <br /> MINE ADDRESS <br /> This Aggregate Industries site accepts inert fill materials including,but not limited to, earth, sand, gravel, <br /> rock, concrete, masonry, asphalt and other inert solids for backfill material. Aggregate Industries reserves <br /> the right to refuse any load upon suspicion that the material might be contaminated or if it contains more <br /> than an incidental amount of wood, vegetation or debris. All information on this form must be completed <br /> and the generator certification signed. <br /> CUSTOMER INFORMATION <br /> Company Name: COMPANY NAME <br /> Address: COMPANY ADDRESS <br /> Contact Name/Phone: COMPANY CONTACT AND PHONE <br /> GENERATOR INFORMATION <br /> Company Name: SITE NAME <br /> Address: SITE ADDRESS <br /> Contact Name/Phone: SITE PHONE <br /> TRANSPORTER INFORMATION <br /> Company Name: COMPANY NAME <br /> Address: COMPANY ADDRESS <br /> Contact Name/Phone: COMPANY CONTACT AND PHONE <br /> INERT FILL MATERIAL INFORMATION <br /> Name of Inert Fill Material Generation Site/Project: SOURCE SITE NAME <br /> Material Generation Site Address: <br /> Contact Name and Telephone: <br /> Material Description (concrete, soil,brick, block, rocks, asphaltic pavement, other): <br /> Soil, concrete, asphalt screened to 6 inch minus. <br /> Type of business or activities at material generation site: Excavation <br /> Aggregate Industries - Inert Fill Materials Profile Form <br /> Page 1 of 2 <br />