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INERT FILL MATERIAL INFORMATION <br />Name of Inert 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 />Type of business or activities at material generation site <br />Known, suspected or potential contamination <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 <br />accurate and complete to the best of his/her knowledge, that fill materials to be delivered to this <br />Aggregate Industries site are clean and inert and that there are no known materials that would <br />significantly affect the inert nature of the fill materials, nor are there any acid forming materials <br />or toxic producing materials in said fill materials. Furthermore, by signing this Statement, the <br />undersigned shall indemnify and hold harmless Aggregate Industries in the event it should be <br />determined that any material provided to Aggregate Industries is contaminated with any regulated <br />pollutant and/or poses environmental harm. The undersigned shall assume all liability and costs <br />Aggregate Industries - Inert Fill Materials Profile Form <br />Page 2 of 3 <br />