Clean Fill Dump Form
Prior to dumping material at any Eureka Stone Quarry, Inc. clean fill site, you MUST have approval. This form is to be completed on a daily basis AFTER any material at a Eureka Stone Quarry, Inc. clean fill site. For each material dumped, a separate form must be completed. Any questions should be referred to the Safety Department.
Which company do you work for?
*
Please Select
James D. Morrissey, Inc.
JDM Materials
Job site that the material was transported from:
*
Name of person submitting this form:
*
First Name
Last Name
Name of supervisor:
*
First Name
Last Name
Which Eureka Stone Quarry site did you transport the material to?
*
Please Select
Tullytown
Rush Valley II
Milford
Was the material tested?
*
Yes
No
Why wasn't the material tested?
Who tested the material?
What type of material did you dump?
*
Please Select
Asphalt/Millings
Blacktop Chunks
Blacktop/Concrete Chunks (Mixed)
Concrete
Concrete Chunks
Dirt
Other
Amount of material dumped:
*
Unit of measure:
*
Please Select
Cubic Yards
Tons
Loads
Truck Information
*
Date the material was dumped:
*
Submit
Should be Empty: