Aggregate Recycling Corporation

A. Customer Information

Customer's Name:

Contact Person:

Phone:

B. Waste Generator's Information

Generator's Name:

Site Address:

Site City:

Site State:

Current Site Usage:

Residential		Commercial
Undeveloped		Other

Process Generating
Waste:

C. Material Description

Approximate the amount of non-recyclables (i.e. debris) requiring off-site disposal in this material %

Clean Waste Wood

C&D Wood

Stumps

Wood Pallets

Logs/Branches

Concrete w/Rebar

Concrete w/o
Rebar

Residential Asphalt
Roofing

Commercial Asphalt
Roofing

Other Wood (describe)

Other (describe)

CERTIFICATION

By checking the "agree" box below, the Generator certifies:

This waste is not a "Hazardous Waste" or "Universal Waste" as defined by USEPA or State of Maine Regulations
This waste does not contain any Asbestos-containing Building Materials
This sheet and any attachments contain true and accurate descriptions of the waste material. All relevant information regarding known or suspected hazards in the possession of the Generator has been disclosed.
If any changes occur in the character of the waste, the Generator shall notify ARC prior to providing the waste to ARC.

I agree to the terms above