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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: N £ 0 D a N P ie O /� wr3 e c (,C 'Poe i4 p U <br /> Owner: ( /rte 'JAI Phone No: <br /> Contractor: G e-o E-o n/ /N C' Phone No: if 8/3 6 O(License No: <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.F., 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 /> _X,B. Crushed rock—self-compacting material not more than three-gcarters (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 /> --3y � <br /> �r SphfH t T 0,,+54 <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of roject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (S 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 tint <br /> * R �Sleiad Gen (o ;sem <br /> - rt <br /> signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 10/16/03) Page 11 <br />