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DocuSign Envelope ID•FF198071-0762-464A-8202-7F56EEDAE 42 I I I B IT A <br /> • ;���- _:,��;.? .�illat�rlal itecytlirlg DescrYptioii aril Ctsrtlf�catioh"°�'�;,p``; ,� '` ..,• ,.' . <br /> Customer Information <br /> Name: Address: <br /> Date&Time of Delivery: <br /> Phone number: <br /> Material Information <br /> Demolished material: [ ]Other(name below) Material Source: [ ]Industrial <br /> ( ]Concrete [ ]Residential [ ]Other(describe below) <br /> [ ]Asphalt I ]Commercial <br /> Material Source Name: Material Source Address: <br /> Material Source Age(approx.): <br /> Hazardous Material Presence <br /> 1.Has asbestos been identified in any structures at the 2.Has an asbestos inspection taken place? <br /> material source?Describe. <br /> 3.If Yes to(1),has the material been segregated from 4.Does the material contain any lead paints,sealants, <br /> known asbestos sources onsite?Describe. treatments,or other possible lead sources? <br /> 5.Has any other hazardous material been identified at <br /> the material source?If Yes,describe. <br /> General Material Information <br /> Estimated Material Quantity: •• <br /> Customer Certification <br /> I certify that the above information is true,to the best of my knowledge.I also certify that I am knowledgeable <br /> of the quantity and quality material being delivered to Newby Aggregate Recycling. <br /> Form Completed By(Print Name) Sign and Date <br /> Newby Agg Recycling Certification of Receipt <br /> Name Sign and Date <br /> Newby Agg Recycling 6 Greg ItekYi and lssoriau:YL1 <br /> April 2020 <br />