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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location <br /> Owner I <br /> t Phone No. <br /> Contractor Phone No y;V !�!'jQ <br /> License No:_� <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> — 1. Submission of Soil Engineer'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 /> _ 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 roject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five f cubic arils gg <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform per <br /> 110Builamg Code <br /> Appendix Chapter 70. <br /> I <br /> I � <br /> ame mt <br /> i <br /> a <br /> t e rmt <br /> w <br /> tgnamre <br /> ` Shall be the responsible managing employee on the license or authorized agent. <br />