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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 3 G 2. q S• A ti=P�R-r\/J A-x( <br /> Owner MA-SStE A-Nro Co . Phone No. g(6 —92.3—goao <br /> Contractor SPCCLIO" GXCs{-0XVU4 Phone No. 68 q -96 5_3 License No. --7 3 A I6} <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.� , 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 pproject 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 /> * A4ic cL- M��,,, <br /> Name rent <br /> �N�. SP�ctgt.(tr — Conwo��Rrt+T�tNoLourE� <br /> — n n e rmt <br /> Signature <br /> Shall <br /> Shall be the responsible managing employee on the license or authorized agent. <br />