2010-11-15_REVISION - M1980244 ‎(182)‎

• Permit No: M1980244
• IBM Index Class Name: REVISION
• Doc Date: 11/15/2010
• Doc Name: QA Monitoring and Test Results 2010, VOL. III, Appendix G.2, PSSA Sec. Liner Subg. Accept. Forms.
• From: CC&V
• To: DRMS
• Type & Sequence: AM9
• Media Type: D
• Archive: No

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CERTIFICATE OF ACCEPTANCE OF SOIL SURFACE
BASED UPON VISUAL OBSERVATION ONLY
I, the Undersigned, the duly authorized representative
of
do hereby accept the area of soil surface bounded
area of soil surface bounded by
\j
NAME SIGNATURE
Reviewed by: 13 Date: 5113/ID
GEOSYNTHETIC INSTALLER PROJECT
COMPANY: Lonestar Lining Co. LOCATION: Cresson Project
ADDRESS: 4520 Half Crown Drive PROJECT: CC&V CQA Phase 5
Dallas, TX 75237 OWNER: Cripple Creek and Victor Gold
and shall be responsible for maintaining its integrity and suitability in accordance with the
project specifications from this date to the completion of the installation.
NAME SIGNATURE TITLE DATE
1, the Undersigned, the duly authorized representative of the CQA Engineer do hereby accept the
sk5)(0
TITLE DATE