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BACKFILL EXCAVATION CERTIFICATE <br />Project Location: 20500 tfOLLY DR lVE <br />Owner: lfOUY SllW <br />Contractor: <br />r <br />Phone No: 04R) F35--3 21 0 <br />Phone <br />License No: <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />�( 2. Submission of verification e.g.: load ticket, within 30 days of project completion that one of the following materials was <br />placed in the excavation in 12" lifts: <br />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 in cross sectional <br />measurement. (Use of crushed rock will not be permitted for backfill if contact will be n ade between the <br />backfill material and tanks/pipes trade 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 ofrcject completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (5� cubic yards per 1000 gallon tank <br />displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 70. <br />* Shall be the responsible managing employee on the license or authorized agent. <br />e <br />