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BACKFILL EXCAVATION CERTIFICATE <br />Project Location Sfi ly <br />Owner"YESQ e r // Phone Nc( �,ti ) w0>: '7-6 ) b <br />ContractorSA0ArTj ,Ue-- 6VO 't�ko <br />"neNo.(w4 <br />r� T'' -Z6 0 License No. 61Lµ/96, <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />l� 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 made between the <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 pproject 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 Utriform Building Code <br />Appendix Chapter 70. <br />* Shall be the responsible managing employee on the license or authorized agent. <br />Rork w A> <br />3/4/ trJ,i,\ Cr\AslaA plc k_ , <br />q I? -AY T°Ns. <br />