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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location C6Ac ^ U3� . <br /> Owner (I re o n Phone No. <br /> Contractor AP L0,) 1 C dA^1 l 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 /> E 2. Submission of verification, e.g., load ticket,within 30 days of project completion that one of the following materials <br /> was placed in the excavation in 12" lifts: <br /> A. Pea gravel—smooth, rounded material not more than one-half(12) 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 <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I herebv certify that a Soil Engineer's Compaction Report will be submitted within 30 days of roject completion,or submission <br /> of 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 Building <br /> Code Appendix Chapter 70. <br /> s <br /> ame rmt) 1l / <br /> qfo eco ✓clty�ct � <br /> I u e pnt <br /> 5tgnature <br /> " Shall be the responsible managing employee on the license or authorized agent <br />