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`/ BACKFILL EXCAVATION CERTIFICA't, / <br />Project Location 103 North E Street <br />Owner A. Teichert & Son, Inc. Phone No. 916-386-3716 <br />Contractor Savidge Construction Phone N0530-622-1982 License No. 755898 HAZ <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.g.: 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 <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 project completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000gallon 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 />* George Takemori <br />Name(Print) <br />* Project Manager <br />tt a rent <br />0Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />*****TEICHERT WILL BACKFILL EXCAVATION USING FILL SOIL FROM OPEN <br />FIELD. SOIL WILL BE COMPACTED TO OUR SATISFACTION FOR THE <br />INTENDED USE. <br />