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V � <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location S� N n L l i 1i.j c . U Fl i )10 Fe Ae r <br />Owner pe r Phone N4 JtjC ] (165c:l (J <br />Contractoc5Ai I c j, J�C N4 Kc* "O one No.( <br />w `� �(6; 7'b 16 License No._ye <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />1� 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 trade 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 da s of project completion, or submission of <br />verification that the select material described above will be placed at a minimum of trve (5p 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 />