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BACKFILL EXCAVATION CERTIFICATE <br />Protect Location Henry Hansen Property, <br />200 S. Cherokee Lane, Lodi, CA 95240 <br />Owner Henry Hansen c/o Right way , <br />Inc. Phone No. (20369-7335 <br />Contractor JIM THORPE OIL, INC. Phone No. (209)368-6175 LicenseNo.495699 <br />INDICATE MEI'HOD OF BACKFILL QUALITY ASSURANCE <br />_ I. Submission of SoII Engineer's Compaction Report within 30 days or project completion, or <br />X 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 />X_ 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 />ct will for backfill If couts <br />heabackfillnmaterial and tause or nks/pipes rock made of pl not be oly resin glass or similar materials.) a made between <br />DECLARATION <br />1 berety certify Ihnl a Suit Engineer's Compaction Report will be submitted within 30 da yys of ��roject completion, or submission <br />mum off <br />dof isplacementttand that theflim the ect entire excavation will be backfilled erial described above will be and compaclaced at a redito Insurecompliancewith theards Uner iffolrlgitaiBuilding <br />Code Appendix Chapter 70. <br />• JIM THORPE OIL,INC. <br />ame r nt <br />• CONTRA " i <br />• 'i� r n ,�,.�� <br />tgnature <br />• Shall be the responsible managing employee on the license or authorized agent. <br />