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Known, suspected or potential contamination: None <br /> Estimated quantity(tons, yards): X,000 cubic yards <br /> Delivery dates (start to finish): Jan 1, 2019-Dec. 31, 2021 <br /> Shipping method (truck type/size): Dump trucks, aggregate trucks 10-25 tons per load <br /> GENERATOR CERTIFICATION AND INDEMNIFICATION STATEMENT <br /> The undersigned certifies that the information contained in and attached to this profile is accurate and complete to <br /> the best of his/her knowledge,that fill materials to be delivered to this Aggregate Industries site are clean and inert <br /> and that there are no known materials that would significantly affect the inert nature of the fill materials,nor are <br /> there any acid forming materials or toxic producing materials in said fill materials. Furthermore,by signing this <br /> Statement,the undersigned shall indemnify and hold harmless Aggregate Industries in the event it should be <br /> determined that any material provided to Aggregate Industries is contaminated with any regulated pollutant and/or <br /> poses environmental harm. The undersigned shall assume all liability and costs associated with the removal, <br /> disposal and negative impacts of any contaminated material provided to Aggregate Industries. <br /> Company: <br /> Name: ,. 1 <br /> Title: <br /> Signature: V <br /> Date: <br /> For Aggregate Industries Use Only <br /> Profile reviewed by Environmental: <br /> Name: <br /> Title: <br /> Signature: <br /> Date: <br /> ❑ Accepted ❑ Rejected <br /> Aggregate Industries - Inert Fill Materials Profile Form <br /> Page 2 of 2 <br />