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NAM� AW� <br /> 9075 WCR 10 *Fort Lupton,CO 80621 <br /> PHONE:303-857-1754 <br /> FAX:303-857-2933 <br /> www.ncconstructors.com <br /> Estimated quantity(tons,yards): <br /> Delivery dates(start to finish): <br /> Shipping Method(truck type/size): <br /> GENERATOR CERTIFICATION AND INDEMNIFICATION STATEMENT <br /> The undersigned certifies that the information contained in and attached to this profile is accurate and <br /> complete to the best of his/her knowledge,that fill materials to be delivered to this Northern Colorado <br /> Constructors, Inc. (NCC)NCCI Pit 41 site are clean and inert and that there are no known materials that <br /> would significantly affect the inert nature of the fill materials,nor are there any acid forming materials or <br /> toxic producing materials in said fill materials. Furthermore, by signing this Statement,the undersigned <br /> shall indemnify and hold harmless NCC in the event it should be determined that any material provided to <br /> NCC is contaminated with any regulated pollutant and/or poses environmental harm. The undersigned <br /> shall assume all liability and costs associated with the removal,disposal and negative impacts of any <br /> contaminated material provided to NCC. <br /> Company: <br /> Name: <br /> Title: <br /> Signature: <br /> Date: <br />