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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: AV E LD2Ncit O e= wClae L t� Cf � fjo gee 19 D 0 <br /> Owner: (' // e f S'l0 O&r-O Al Phone No: &/L9, 7 — d <br /> Contractor: G G o o N /'IV 0 Phone No: C9/6 X 8/-? 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-qquarters (3/4) inch in cross sectional <br /> permittedmeasurement. (Use of crushed rock will not be permitted for bac III if contact will be made between the <br /> backfill material and tanks/pipes made of poly resm glass or similar materials.) <br /> �y <br /> ­,4J Phl)f 4 T Qr J(Ei <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 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 /> I <br /> Name rent <br /> Title(Print) <br /> ■ <br /> tgnature <br /> " Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 10/16/03) Page 11 <br />