SOURCE APPROVAL FOR FINE AGGREGATE

PART I:  (PRODUCER REQUEST)

Producer:        Source Name: 

Location:    Sec    Twp   Rng    County: 

By:        Date: 

PART II:  (SOURCE DESCRIPTION - By Producer)

Overburden:    Production Depth:   Above Water: 

PART III:  (PRODUCTION TESTS)

Lab #            Mtr St        3/8         #4        #8        #16        #30        #50        #100       #200       Shale

PART IV:  (DISTRICT RECOMMENDATIONS)

By:        Date: 

PART V:  (CENTRAL OFFICE DETERMINATION)

Approved:       Date: 

T203 Code No.: