Author: Chrissie Manis

Dirt/Fill Questions? (708) 447-1100 x 3

Incoming Fill Application

Facility Applied For:

Lyons — 4401 S 1st Ave Lyons, IL 60534

Pulaski — 3741 S Pulaski Rd Chicago, IL 60623

Thornton — Derby Rd & Ridge Rd, Thornton, IL

Project Information:

Project Street Address: _____________________________________________________
City ____________________________________ State ____ Zip ________________
Purchase Order # _______________

Scope of Work: _______________________________________________________

Type of Incoming Material

*Anticipated Load Quantity____________
*Required 2014

Uncontaminated Soil

Brick

Reclaimed Asphalt Pavement

Concrete w/o Protruding Metal

Other: _______________

Misc Project Information:
General Contractor ________________________________________________
Gen. Contractor Business Address _____________________________________
Gen. Contractor Phone # _______________

IEPA CERTIFICATION ATTACHED:
LPC-662 Form (No Known Environmental Concerns) OR LPC-663 Form (Potentially Impacted by Environmental Concerns)

Customer Billing Information:
Company Name ________________________________
Mailing Address _____________________________________________
City _______________________ State ___________ Zip ________________
Phone Number ______________________ Fax or Email _______________________

Printed Name ____________________________________________________
Signature ________________________________________________________
Title ____________________________________________________________
Today’s Date ____________________

Email to fill@reliablematerials.com OR Fax to 630-524-9020

Revised January 2014