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BACKFILL EXCAVATION CERTIFICATE <br />Project London Zy <br />Owner - � Fa one 4r_ e,7) <br />r�ntr.r.nr.c�_"�'GiL_ Phone No License No/O <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Eng'ineer'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 />_�, 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 crusbed rock will not be permitted for backfill if contact will be made between the <br />backfill material and tankslpipes made of poly resin glass or similar materials.) <br />DECLARATION <br />1 hereby certify that a Soil Engineer's Compaction Repon will be submitted within 30 days ofpproject 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 ballon tank <br />displacemem and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 90. <br />• Shall be the responsible managing employee on the license or authorized agent. <br />