2010-11-15_REVISION - M1980244 ‎(175)‎

• 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.3, PSSA Pri. Liner Subg. Accept. Forms.
• From: CC&V
• To: DRMS
• Type & Sequence: AM9
• Media Type: D
• Archive: No

• CERTIFICATE OF ACCEPTANCE OF SOIL SURFACE
BASED UPON VISUAL OBSERVATION ONLY
•
COMPANY:
ADDRESS:
GEOSYNTHETIC INSTALLER
Lonestar Lining Co.
4520 Half Crown Drive
Dallas, TX 75237
I, the Undersigned, the duly authorized representative of
do hereby accept the area of soil surface bounded by
- 30% 1' 3■ 3
• agme4s �� /� ( '
NAME SIGNATURE
NAME
Lonestar Lining Co.
Reviewed by:
TITL
I, the Undersigned, the duly authorized representative of the CQA Engineer do hereby accept the
area of soil surface bounded by
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.
PROJECT
LOCATION: Cresson Project
PROJECT: CC&V CQA Phase 5
OWNER: Cripple Creek and Victor Gold
Date:
I/ iv/ 2-01
DATE
`Ntobo
DATE