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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: 24 ' Ae__n2n/� (- <br /> Owner. Jt��'' �iZs Phone No: 3 13 <br /> Contractor i hOn'T� Q�L Phone No: License No: <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineels 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" lift.: <br /> 1 A. Pea gravel—smooth,rounded material not more than one-half(I/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 �atlon 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 /> JfFF�f� /CiiZI7 <br /> ame n[ <br /> L= <br /> n e nt) <br /> azure <br /> • Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 10/16/03) Page 11 <br />