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Mak ,Aw� Adp� <br /> 9075 WCR 10 *Fort Lupton,CO 80621 <br /> PHONE:303-857-1754 <br /> FAX:303-857-2933 <br /> www.ncconstructors.com <br /> EXHBIT C -INERT FILL MATERIALS PROFILE FORM <br /> DRMS Permit M-2001-107—NCCI Pit#1 <br /> 8249 County Road 25, Fort Lupton CO 80621 <br /> This Northern Colorado Constructors, Inc. (NCC)NCCI Pit#1 site accepts inert fill materials including, <br /> but not limited to,earth, sand,gravel,rock,concrete, masonry, asphalt and other inert solids for backfill <br /> material.NCC reserves the right to refuse any load upon suspicion that the material might be <br /> contaminated or if it contains more than an incidental amount of wood, vegetation or debris.All <br /> information on this form must be completed and the generator certification signed. <br /> CUSTOMER INFORMATION <br /> Company Name: <br /> Address: <br /> Contact Name/Phone <br /> GENERATOR INFORMATION <br /> Company Name: <br /> Address: <br /> Contact Name/Phone <br /> TRANSPORTOR INFORMATION <br /> Company Name: <br /> Address: <br /> Contact Name/Phone <br /> INERT FILL MATERIAL INFORMATION <br /> Name of Iner Fill Material Generation Site/Project: <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 of activities at material generation site: <br /> Know, suspected or potential contamination: <br />