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..i <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location:ir�L _lffYleliG�ist VitYLNLiC, <br />Owner: Phone No: l / <br />Z��) 7'� ZCiE-) <br />Contractor: lV `( Phone No: (ZC `i� <br />License No: lx' �7 i 1�0 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project <br />completion, or <br />b° 2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br />one of the following materials was placed in the excavation in 12" lifts: <br />A. Pea gravel --smooth, rounded material not more than one-half (1/2) <br />// inch in diameter <br />v! B. Crushed rock--self-compacting material not more than three-quarters <br />(3/4)) inch in cross sectional measurement. (Use of crushed rock will <br />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 <br />materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br />wi project completion, or submission of verification that the select material described above <br />will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br />that the entire excavation will be backfilled and compacted to insure compliance with the <br />Uniform Building Code Appendix Chapter 70. <br />oiltj Lqw <br />4m tA4 c <br />Shall be the responsible managing employee on the license or authorized agent. <br />