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BACKFILL EXCAVATION CERTIFICA' <br /> Project Location /Z 7 �7 • /9 <br /> Ownerf✓c�i.� W/� t Phone No. S • t 6— 1d <br /> ContractorXp / &.A,0Fi ��•�,Li✓r�.Phone Nq�jO X39 •10IXSLicense No.y7 Sd,?7 <br /> W T <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 0/2. 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 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 �inform Building Code <br /> Appendix Chapter 70. Q� 7, <br /> 3 •-- Ihe <br /> Pnn L <br /> G- 1..� fCJ <br /> ame rmt <br /> * •c G r9a <br /> it rint <br /> * <br /> ignamre <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />