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\\ BACKFILL- EXCAVATION CERTIFICATE <br /> Project Location Ll� c) N, Q)S, )lSL&bt'4L I <br /> Owner \l Phone Na. (b�> 44 ' 3`555 <br /> Contractor_'��aa 17{ T _Phone No4-)y)SZ -b35z License No. -�DOi`15 <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(112) 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 da sof pprojecr 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 Utriform Building Code <br /> Appendix Chanter 70. <br /> IC UN t11t1 w' r�•R� l <br /> t ante ( t) <br /> ytL � a - <br /> t e( q <br /> —© tgnazure <br /> " Shall be the responsible managing employee on the license or aurhorimd agent. <br />