J5_RSA Landfill Delivery Ticket.pdf

ADEM Permit No. 45-03

Redstone Arsenal Construction and Demolition Landfill Material Certification

Date:

Gov. Proponent POC (Name): Phone:

Contractor POC (Name):

Contractor (Company Name):

Subcontractor 1 (Company Name):

DO Log Number:

Point of Origin of Waste:

FBI Army NASA

Building Number:

Construction Site:

Other (specify):

Project Description:

I certify as the Proponent POC that the project & material described herein is correct to the best of my knowledge.

(Signature of Proponent POC)

Type of Recyclable: (circle)

Concrete Asphalt (milled) Trees

Other:_____________________________ Soil for Cover

Type of C&D Waste (check all that apply):

Sand

Scrap Metal (non-recycle)

Sheetrock/Plaster

Soil

Treated Lumber

Yard Waste

Wood Ash

Wood Waste

Material Certification: I certify that this form accurately describes the material permitted to be delivered to the Redstone landfill, and that it does not contain hazardous, CERCLA, medical, toxic, PCB-contaminated, or radioactive waste.

Date:

Phone:

Phone:

Expires:

Certification Number:

Bldg. No:

Phone:

Onsite Bldg. No.:

Phone:

Asbestos

Asphalt (Un-milled)

g. Material (specify):

st. Rubble

Insulation

Masonry Waste

Rock

Roofing

Signature:

(Garrison Environmental Office) Name:

MSFC-AD10 (Marshall Space & Flight Center) Name:

Email:

Valerie Mason 876-1899 valerie.a.mason2.civ@mail.mil

Attachment J5 Delivery Ticket 1 May 2023

ADEM Permit No. 45-03 Redstone Arsenal Construction and Demolition Landfill

DELIVERY TICKET

AM PMTime:

Date:

Certification Number:

Vehicle License Number:

Name of Vehicle Driver:

Phone Number:

Delivery By:

Contractor (Name):

Government (Office Symbol):

Point of Origin:

Army Other:

NASA FBI

Building Number:

Construction Site:

Other (specify):

Volume of Material Delivered:

Tons

Cubic Yards

Type of C&D Waste in Load (check all that apply): Type of Recyclable in Load (circle item or note “other”):

Asphalt (Milled)

Concrete

Trees Other:

Soil for Cover

Comments:

Asbestos (appropriate forms attached) Asphalt (Un-milled) Bldg. Material (specify):

Const. Rubble Scrap Metal (NR) Yard Waste Insulation Sheetrock/Plaster Wood Ash Masonry Waste Soil Wood Waste Rock Treated Lumber Roofing Sand Other (specify):

Certification: I certify that this load of material delivered to the Redstone C&D Landfill and the information on this form accurately describe this material, and that it does not contain free liquid; dead animal; garbage; trash; or petroleum product-containing material.

Signature:

(name) (date)

Printed Name:

Attachment J5 Delivery Ticket 1 May 2023