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aCKFILL EXCAVATION CERTIFICATE <br />Project Location Ro–Tile, 310 N. Cluff Ave Lod; , Ca 85249 <br />Owner Lavor Thompson Phone No. (209)369-4751 <br />Contractor Jim Thorpe Oil, Inc. Phone No. (209)368-6175 Licensetio.495699 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of 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 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 <br />the 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 orojec_t completion, or submission of <br />verification that the se!ect material described above will be placed at a minimum of five (5) t5ubic yards per 1000 gallon tank <br />displacement and that the entire excavation will be backfilled and compacted to insure complianc <br />Appendix Chapter 70. e with the Uniform Building Code <br />* Jim Thorpmee 011Tn�. by Ri rha rA 111 --pe <br />Nat :tat— <br />* Con ctor <br />gnamre <br />Shall be the responsible managing employee on the License or authorized agent. <br />