Principal Contractor/Occupier: Name

Customer Name: Name

Site Address: Address

Previous History/Use of site: History

Reports Attached?

Zoning:

• Industrial

• Commercial

• Domestic

• Greenfield

Soil Description:

Type: Type

Estimate Quantity: Quantity

• Wet

• Top Soil

• Sub Soil

• Silt

• Clay

• Bedrock

• Dry

Evidence of Industrial Waste: Evidence

Color:

I certify that I have undertaken an assessment of the materials being supplied in accordance with the IWRG 621 Soil Hazard Categorization and Management.

Inspected By: Name

Signed By: Sign

Date: Date

Approved Clean Fill Receipt

(Receiver)

I confirm that I have received and read this assessment. The site assessment states that the materials is Clean Fill. I have also inspected the material before accepting it and see no evidence that other wastes are mixed in the load and did not detect any odor.

Fill Site: Site

Inspected By: Name
Date Received: Date

Accepted or Rejected: