Doc. No.

ACCOUNTABILITY FORM Effective Date

Revision No.

Name of Employee: Control No.

Department: Issuance Date:

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I hereby acknowledge the receipt of the following item(s) from Southern Star Aggregates Inc. (SSAI)

Issuing Department: Plant:

Issued By: H.O
Item Description Q'ty Unit SN

Above item(s) is/are property of xxx. Any lost of the above, the recipient shall pay the lost item.
If the item is damaged, please contact the issuing personnel to assist you.
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Received the above item/s in good condition Returned the above item/s in good condition

By: By:

Date: Date: