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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location ?A-_ TSL. <br /> Owner �/}GtpCL —]t_ Phone No. 41 ZYv/ <br /> Contractor A Va4 � / P t(br Phone No. I6License No. 5'72016 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineers Compaction Report within 30 days of project completion, or <br /> ,Submission of verification, a g., load ticket, within 30 days of project completion that one of the follap cg materials <br /> was placed in the exca<<rion in 12" lifts: <br /> ✓Pea gravel-smooth, rounded material not more than one-half(1R) inch in diameter <br /> ► _ B. Crushed rock--self-compacting material not more than three-quarters (3/4) inch in cow sectional <br /> meaSUremetlL (Use of crushed rock will not be permitted for backfill if contact will t,-=sde between <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> ► <br /> DECLARA'T'ION <br /> I hereby certify that a Soil Engineers Compaction Report will be submitted within 30 days ofroject completion,or submission <br /> n <br /> of verificatiothat the select material described above will be placed at a minimum of five (5�cubic yards per 1tkV:Tallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Lm,,nm Building <br /> Code Appendix Chapter 70. <br /> Name ( nnt) <br /> • �/1G MZL- 6,;A1Udc <br /> u e ( rmt <br /> Sigp Lure <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br /> r <br /> ► <br />