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�IACKFILL EXCAVATION CERTIFICATE <br /> Project Location 442 N. Airport Way, Stockton, CA 95205 <br /> Owner Don and Celia Nathe Phone No. (209)943-7134 <br /> Contractor Jim Thorpe oil , Inc. Phone No.(209)368-6175 License No. 495699 <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.p load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12 life: <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 no[ be permitted for backfill if contact will be made between . <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials.) _ <br /> X C. Lines will be filled with 2 sack concrete slurry . <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 da s of pproject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (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 /> * Jim Thorpe Oil , Inc . <br /> ame rm[ <br /> * Presiden <br /> e r <br /> tgnamre <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />