Land and Lakes-Soil Frofile Form

	SOIL PROFILE FORM

Company/Client Name
Phone Number
Contact Name
Contact Email
Hauler Name

Site/Generator Name
Site Address
Duration of Job
Number of Loads

Type of Site:

	Industrial
	Commercial
	Residential
	Farmland

Type of Material:

	Soil
	Brick
	Concrete
	Asphalt

Note any of the following:
Herbicide, Pesticide, Fertilizer w/in last year?	Yes	No
Is this a Parking Area?	Yes	No
Septic System near excavation?	Yes	No
Above Ground Fuel Tanks near excavation?	Yes	No
Underground Fuel Tanks near exacavation?	Yes	No
Rail Road Tracks near excavation?	Yes	No
Vehicle Repairs done on site?	Yes	No
Any known spills of petroleum products?	Yes	No
Dry cleaner or gas station within 100 feet?	Yes	No
Previous LUST Site?	Yes	No

Explain any of the above:

Material shall be “Clean Construction Debris” within the meaning of the Illinois Environmental Protection Act, 415ILCS 5/3.160(b), which defines “clean construction debris” as “broken concrete without protruding metal bars, rock, stone, reclaimed asphalt pavement, or uncontaminated dirt or sand generated from construction activities.” Materials such as concrete and asphalt pavement shall be separated from granular fill prior to placement on the Receiving Site so as to make such material suitable for processing as recycled material.