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BACKFILL EXCAVATION CERTIFICATE <br /> Project/Location l../1 /'6 rao (14 �]t p - /, <br /> Owned.-.i 7! /1q Phone No.d(/-OJ- 7aa <br /> Contractor Phone No. 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(U2)inch in diameter <br /> B. Crushed rock--self-compacting material not more than threo-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 Uniform But Code <br /> Appendix Chapter 70. <br /> s <br /> Name rent <br /> rte rent <br /> Signs re <br /> Shall be the responsible managing employee on the license or authorized agent. <br /> I <br />