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Project <br />Owner <br />BACKFILL EXCAVATION CERTIFICATE <br />1444 N. E1 Dorado St., Stockton, CA 95202 <br />Phone No. (209)669-2610 <br />Contractor JIM THORPE OIL. INC. — Phone No. (209)368-6175 License No.495699 <br />INDICATE ME7110D OF BACKFILL QUALI'T'Y ASSURANCE <br />1. Submisslon of Soil Engineer's Compaction Report wllhin 30 days of project completion, or <br />2. Submission of vetificalion, e.g., load ticket, within 30 days or project completion that one of he following materials <br />was placed in the excavation in 12" Ilfts: <br />_ A. Pea gravel --smooth, rounded material not more than one-half (1/2) inch in diameter . <br />_ B. Crushed rock--scif-compacting materbd not more than Uveegaarters (3/4) Inch In cross sectional <br />mesuremeliteabackRllnt. tcrushedUse or <br />maeri l andtmtks/pipcs made f poly rrdresin glass or similar materials(or backAll If contact ' be made between <br />) <br />DECLARAI'ION <br />I bcteby cel Iffy that a Soil Eoginecr's Compaction Report will be submitted wllhin 30 da s or roject completion, or submission <br />of verillcatiolt that lite select material described above will be placed at a minimum of five (5� cubic yards per 1000 gallon lank <br />nsure compliance with lite Uniform Building <br />displacement and that lite entire excavation will be backrilled and compacted to i <br />Cale Appendix Chapter 10. <br />+ JIM THORPE OIL,INC. <br />ame ( r nt <br />• CONTWI: <br />lgnature <br />' Shall be (lie responsible managing employee on the license or authorized agent. <br />