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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location S G 2 g S . A I2PotzT W�f <br /> Owner M A-SS t E hNr�U Co . Phone No. (6 —R Z3—qoo o <br /> Contractor SPCC LAAAr) C7C"4Nr?AAj Phone No. SS q -96 5--7 License No. J 3y 1fi4- <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 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 dayys of pproject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of fve (S) 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 /> • M)rlt-J�C` M��l�t rrs <br /> Name <br /> SPeC-141_J 1T' _ -DAU1oK OLUG�IEJ <br /> n n e rmt <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> 1 <br /> Ji <br />