Laserfiche WebLink
ICKFILL EXCAVATION CERTIFICATE <br /> Project Location /", '—/" <br /> Owner V►y\ cS I'k-�n 4/ � t�t t)I E7R ff//�, � 'Phone No. '7�f � Q���^ <br /> Contractor ftd vert MR Sep &f1,Phone No. 7b7—)OD/O License No. e07( DZZ_7 <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.Fload ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12 lifts: <br /> ZA. 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 <br /> the 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 /> Name (Print) <br /> u e rm <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />