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L) <br /> MAR 10 201160 <br /> BACKFILL EXCAVATION CERTIFICATE ENMRDNIMENTAL <br /> M-Ik!-.t`ht751;r7T <br /> Project Location:. Z��3 �// P�- <br /> Owner Phone N o /2 <br /> Contractor-- Phone No:2 c,> !Z lyll <br /> License No, <br /> L <br /> MAY 0 5 2016 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE - <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> 9pe e following materials was placed in the excavation in 12" liftT <br /> A. ea gravel--smooth, rounded material not more than one-half(1/2) <br /> i ch in diameter <br /> B. rushed rock--self-compacting material not more than three-quarters <br /> 3/4)einch in cross sectional measurement, (Use of crushed rock will <br /> not permitted for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin glass or similar <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> project completion, o submission of verification that select material described above <br /> of belace at a minimum of five (5 cubic yards per 1000 gallon tank <br /> will displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70, <br /> *Name �','1_1_—Iezo <br /> (FIr <br /> Title <br /> (Prim) <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> ;n <br />