Unprocessed Asphalt Shingles Delivery Certification Form (Form 820010a)

delivering ENTITY

Company Name

Address

Phone

Contact Name

Address of Shingle Source

License Plate Number

ACCEPTING ENTITY

Company Name

Address

Phone

Contact Name

□  Post-consumer	□  Pre-consumer
(Check One)

We undersigned certify the following:

1.  tons of whole, unprocessed asphalt shingles have been delivered for processing. (Report number of tons)

2. The delivered material is from a NESHAP exempt structure or documentation stating the material does not contain asbestos has been submitted. The material has not been in contact with hazardous wastes and consists of asphalt shingles and normal roofing debris only.

3. Delivered asphalt shingles have been tested or inspected for asbestos-containing materials (ACM) by (provide trainee name and certification number) who has been trained to identify ACM by ______________________________ (provide training program name). Suspected ACM have been rejected.

□  Accept	□  Reject
Comments:

Delivering Entity (signature)                                                               Date

Accepting Entity (signature)                                                               Date