Form Fp 001 – Fill Out and Use This PDF

2500-FM-BWM0008 Rev. 8/2010	COMMONWEALTH OF PENNSYLVANIA
	DEPARTMENT OF ENVIRONMENTAL PROTECTION
	BUREAU OF WASTE MANAGEMENT

FORM FP-001 - CERTIFICATION OF CLEAN FILL

Prior to completing this form and signing this certification, please review the entire Management of Fill policy (#258-2182-773), including the certification requirements. Please note that historic fill, as defined in the Management of Fill policy, may meet the definition of clean fill if the material is limited to uncontaminated soil, rock, stone, dredged material, used asphalt, and brick, block or concrete from construction and demolition activities that is separate from other waste and recognizable as such.

Instructions: Sections 1 and 2 of this form must be completed by the person making the determination of clean fill at the site of origin. Section 3 must be completed by the person using the material as clean fill. Both the person determining clean fill and the user of the clean fill are responsible for maintaining copies of this completed form on site for a period of five (5) years for Department inspection.

Section 1: Person Determining Clean Fill

Name (Print):

Title:

Date:

Company Name:

Street Address:

City:

State:

Zip Code:

Telephone Number:

E-mail Address:

Clean Fill Material originated on the following property:

Site Name:

Street Address:

City:

State:

Zip Code:

Section 2: Site Characterization

Check the following that applies:

A. IF the site of origin for the fill material has undergone or is undergoing cleanup or remediation pursuant to a local state or federal regulatory program that requires site characterization, provide the following information along with a copy of the entire site characterization and laboratory analysis for the material to be used as clean fill.

Name of local, state, or federal agency:

Identification number assigned to the project:

Name of the local, state, or federal contact person:

Telephone Number:E-mail Address:

Name of the Laboratory that conducted the analysis:

Laboratory Accreditation Number:

B. IF the material proposed to be used as clean fill has otherwise been subject to analytical testing or other procedure identified in the definition of “environmental due diligence” contained in the Management of Fill policy, provide or attach the following:

Copies of ALL lab analytical testing performed as part of environmental due diligence (see Management of Fill policy, #258-2182-773).

Name of the Laboratory that conducted the analysis:

Laboratory Accreditation Number:

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2500-FM-BWM0008 Rev. 8/2010

C. IF the proposed material to be used as clean fill was subject to environmental due diligence procedures as defined in the Management of Fill policy other than those listed in A and B, describe those procedures.

I, the undersigned, certify under penalty of law (18 Pa. C.S.A. §4904) that the information provided in Sections 1 and 2 of this form is true and correct to the best of my knowledge, information and belief.

Signature:

Section 3: Person Receiving or Placing Clean Fill

Name and address of person completing this form:

Name (Print):

Date:

Mailing Address:

City:

State:

Zip Code:

Telephone Number:

E-mail Address:

Fill material that has been determined to be clean fill will be placed on the following property solely for property improvement or construction purposes:

Property Address:				City:				State:		Zip Code:
Current Owner of Property:
Telephone Number:					E-mail Address:

The quantity of clean fill to be placed on the property is:

I, the undersigned, certify under penalty of law (18 Pa. C.S.A. §4904) that the information provided is true and correct to the best of my knowledge, information and belief.

Signature:

* * * * *

Prior to placement of the clean fill, the owner of the property receiving fill material shall provide a copy of this completed form and attachments to the DEP Regional Office serving the county in which the receiving site is located. If a property receives fill from multiple sources, a separate Form FP-001 is required for each source.

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