Laserfiche WebLink
(BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 3 13 3 N A d A ✓' t R o o d t 5)o c K }o h <br /> Owner Ad - A I- Phone No. <br /> ContractorAdyorc <d &.a Exviromm-04IPhone Nol} - N67- )DO6 License No. 690 22 7 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _/1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> V 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in theexcavationin 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-quartets (3/4) inch in cross sectional <br /> measurement. (Use of crushed rock will not be permitted for back:Jfill 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 Eve (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 /> Kevivl � K ;6b,h <br /> nme (Print) <br /> ■ 5aNIor 5la'f'f G•o1021'5 <br /> — lite (Print) <br /> nt) <br /> — Signature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />