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02/20/02 13:30 FAX <br />Project <br />BACKFILL EXCAVATION CERTIFICATE �w <br />Owner `-' Phone No. <br />Contractor Phone N��s3 �J--�� License No. SI�r�I <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />M <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />2. Submission of verification, e.g., load ticker,. 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-compaeting material not more than tbree-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 />1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 da s 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 />Shall be the responsible managing employee on the licens <br />nine not <br />