Supplier Certification Form for Manufacturer’s Salvaged and Post-Consumer (Tear-Off) Asphalt Shingles PART I: Supplier Company PART II: Supplier Rep (unless same as PART I) Please indicate best describes the Supplier: Rep’s name: <-Manufacturer <- C&D Rep’s title: <-Homeowner <-Roofing company Supplier name: Rep’s phone: Supplier phone: Rep’s e-mail: Supplier e-mail: Rep’s address (if not same as Supplier main address): Supplier address: PART III: Shingle Verification (Please check the following boxes as directed.) I the undersigned certify that: Mark all that apply. I have completed all appropriate hauler training. All shingle material delivered is from an approved Supplier cited in the Source’s Quality Control Plan. Fill out if you Please check ONLY ONE of the following options: selected or “C&D” (1): Asbestos test results are included, indicating all material is Asbestos Free. Company” “Roofing (2): Asbestos testing has been initiated but is not complete. in PART I. PART IV: To be completed by Trained Hauler/Homeowner Trained Hauler/Homeowner (signature) Trained Hauler/Homeowner (print name) Date For Source Use Only: One or two certified asbestos inspectors may fill out this section over time. Load status: <-Accepted <-Rejected Reason for rejection: _______________________________________________ Delivery Vehicle License: __________________________ _______________________________________________ Certified asbestos inspector (Print name) Certified asbestos inspector (Signature) Date Results of asbestos testing (attached): <-Asbestos Free <-Asbestos found Certified asbestos inspector (Print name) Certified asbestos inspector (Signature) Date
Supplier Certification Form for Manufacturer’s Salvaged and Post-Consumer (Tear-Off) Asphalt Shingles PART I: Supplier Company PART II: Supplier Rep (unless same as PART I) Please indicate best describes the Supplier: Rep’s name: <-Manufacturer <-Homeowner <- C&D <-Roofing company Rep’s title: Supplier name: Rep’s phone: Supplier phone: Rep’s e-mail: Supplier e-mail: Rep’s address (if not same as Supplier main address): Supplier address: PART III: Shingle Verification (Please check the following boxes as directed.) Mark all that apply. I the undersigned certify that: I have completed all appropriate hauler training. All shingle material delivered is from an approved Supplier cited in the Source’s Quality Control Plan. Fill out if you selected “C&D” or “Roofing Company” in PART I. Please check ONLY ONE of the following options: (1): Asbestos test results are included, indicating all material is Asbestos Free. (2): Asbestos testing has been initiated but is not complete. PART IV: To be completed by Trained Hauler/Homeowner Trained Hauler/Homeowner (print name) Trained Hauler/Homeowner (signature) Date For Source Use Only: One or two certified asbestos inspectors may fill out this section over time. Load status: <-Accepted <-Rejected Reason for rejection: _______________________________________________ Delivery Vehicle License: __________________________ _______________________________________________ Certified asbestos inspector (Print name) Certified asbestos inspector (Signature) Date Results of asbestos testing (attached): <-Asbestos Free <-Asbestos found Certified asbestos inspector (Print name) Certified asbestos inspector (Signature) Date
BMPR%20RASSPL.docx