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�7 BACKFILL EXCAVATION CERTIFICATE <br /> Project Location ZU61 t_:oct✓t E� bg6 <br /> Owner ('tet Phone No—(W11) <br /> Contractor SIT4CO Phone No. (209) 524-9653 License No. 449864 <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" life: <br /> �C 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 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 days of project 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 Uniform Building Code <br /> Appendix Chapter 70. <br /> + JCtC�t NK�I K <br /> a " Name t <br /> D <br /> 1W Ln'Pyr <br /> i e not <br /> I <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />