RECLAMATION FILL SOURCE - glasgowinc.com

Please complete, sign and submit this form with any relevant environmental due diligence information pertaining to the fill SOURCE and submit to glasgow , Inc. FOR OFFICE USE ONLY: Rejected Reviewed By: Date: A ccepted glasgow , Inc. SOURCE #: RECLAMATION FILL SOURCE APPROVAL INFORMATION SHEET Contractor/Customer Information Company: Name & Title: Property Address: Customer #: Phone: City, State & Zip: Email: Jobsite/Material Information RECLAMATION Facility Property/Project of Origin: Ivy RockMcC oyMontgomery Stone Property Address: Start date: Est. Vol. (CY): City, State & Zip: End date: Est. # of Loads: Due Diligence/Materials Description (Please fill out & check all that apply to the generating site.) Generating Site Type of Material Industrial/C ommercial Residential Hospital/ University Utility ONLY brick, block, stone, concrete, rock, asphalt breakup ONLY Uncontaminated soil Mix of the above Material has been subject to known spills or releases or other means of potential contamination by regulated substancesMaterial has been tested and analysis is attached Additional Co

Please complete, sign and submit this form with any relevant environmental due diligence information pertaining to the fill s ource and submit to Glasgow, Inc.

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