Aggregate Certification of Compliance

Airport: IL Project No.: AIP Project No.: Contractor: Project Description:

It is hereby declared that the aggregate from producer/supplier number was supplied for use to . The gradation(s) supplied from this source is . The aggregates conforming to this gradation meet or exceed the quality and freeze-thaw (if specified) requirements for a class quality aggregate as defined in Sections 1003, 1004, and 1005 of the IDOT Standard Specifications for Road and Bridge Construction and are produced in accordance with the IDOT AGCS (Aggregate Gradation Control System). The quantity of this aggregate that was supplied to the aforementioned plant is tons. A representative delivery ticket is attached hereto and there are delivery tickets accounting for the full quantity of aggregate delivered which are available to the project Resident Engineer and are also filed and available upon request.

The undersigned representative of (Aggregate Source) attests, to the best of his or her knowledge and belief, that: This statement is a material representation of fact upon which reliance will be placed when payment is made on the subject contract to .

(Signature of Aggregate Company Representative)

This statement is being made under oath, subject to all pertinent civil remedies and criminal penalties including fraud, theft, and perjury. Signed and sworn or affirmed before me, , a notary public, this day of , 20 .

Notary Public

My commission expires:

The original signed copy of this form must be submitted to the Illinois Department of Transportation, Division of Aeronautics, 1 Langhorne Bond Drive, Springfield, IL 62707-8415, Attn: Materials/Construction. To expedite processing this completed signed form may be scanned and emailed to [email protected] or faxed to (217) 785-4533.

Printed 4/8/18 AER 18 (08/09/10)