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•�Y <br />M1•1 • <br />BACKFILL E%CAVATION CERTIFICATE <br />Project Location: 20500 lf/l-L(-) 1)12V2F <br />Owner: 51,16r?2 <br />Contractor•— <br />Phone No: <br />Phone No: License <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />X 2 Submission of / excavation to 12" ., lad ticket, within 30 days of project completion that one of the follow <br />placed in the <br />N A. Pea gravel --smooth, rounded material not more than one-half (1/2) inch in diameter , <br />B. Crushed rock--self-compacting material not more than three-quarters (3/4) inch v <br />measurement. (Use of crushed rock will not be permitted for backfill if contact will be <br />backfill material and tanks/pipes made of poly resin glass or similar materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of roject c <br />verification that the select material described above will be placed at a minimum of five (5� cubic <br />displacement and that the entire excavation will be backfilled and compacted to insure compliance with <br />Appendix Chapter 70. <br />s <br />* Shall be the responsible rnana&g employee on the license or authorized agent. <br />EY1Jt%Z�1r✓1P�1 �f'�'iahec.�' <br />N <br />AUG 2 9 2003 <br />ENVIRONMENT H <br />SERVICES <br />materials was <br />sectional <br />ween the <br />or submission of <br />1000 gallon tank <br />m Building Code <br />