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COMMUNITY DEMOPMENT DEPARTMENT <br />/i 1610 E NAZEITON AVE. STOWOR G 95M6 <br />OE"'Op" SERVICES PHONE: 1606) 448.5120 <br />MANN 1O PHONE: 12061 466.310 <br />null" PHONE: 1091166-3123 <br />"E O *OW1000 Pn6 AVA"ON PHONE 12091 416.2071 <br />BACKFILL XXCAVATION CERTIFICATB <br />Project Location 3 P� Sraif 70�/ <br />Owner �%�pT �g/�/rPENGE <br />Phone No. <br />Contractor) �iE�ICo Phone No.Z( <br />S3 License No. �Wlgz <br />INDICATE METHOD OF BACKFILL QUALITY AsBuRAM cc <br />1. BubmirslOn of soil tngineerls Compaction Report within 30 days of project <br />E:mpletion, or j <br />2• Bubmisalon of verification, e.g. load ticket, within 30 days of project <br />(completion that one of the following materials was placed•in the excavation In <br />12" Iter <br />' <br />V A. <br />Pas gravel -,smooth, rounded material not more than one-half (1/2) <br />Inch in diameter. <br />B• crushed rock - self -compacting material not more than three-quarters <br />willnot <br />Inch in cross sectional <br />be permitted forbackfillsifecontact will be made between <br />the backfill material and tanks/pipes made of poly resin glass or <br />similar materials.) <br />DECLARATION <br />I hereby certify that a soil Rnginaar'a Compaction Report will be submitted within 30 days <br />of <br />project <br />completion, or submission of verification that the nal material described above <br />will be placed at A minimum of five (S) cubic yards per 1000 gallon tank displacement and <br />that the entire excavation vyill be backfilled and compacted to insure compliance with the <br />Uniform Building code Abpandi,x Chapter 70, <br />I Name (pr nr) <br />C S7/�%,q7-d2 <br />Tte (Prat <br />! S gnatur <br />* ----- <br />Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/8SC9RT.DOc <br />