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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 4025 Coronado Avenue, Stockton, CA 95204 <br /> J.H. Simpson Company Phone No. (209)466-1477 <br /> Owner <br /> Contractor JIM THORPE OIL. INC._ Phone No. (209)368-6175 License N0.495699 <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.Q., 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(I/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 berchy certify that a Soil Engineer's Compaction Report will be submitted within 30 daysof roject completion,or submission <br /> of verification that the select material described above will be placed at a minimum of fiv (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 /> • JIM THORPE OIL,INC. <br /> ame nnt) <br /> ' CONT "'0 <br /> It <br /> igr e <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />