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BACKFILL EXCAVATION CERTIFICATE <br /> Project Loc� �L <br /> Location: Gfs-s :5.' � 4!q4 � j/ /- <br /> Owner: 'S &JL6 4m Phone No: q)Z, &- 67t�� / <br /> Contractor: VA i i� f,644d JM4£ Phone No/ qW rk)t//—20 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. ., 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 pemritted.for backfill if contact will be made between the <br /> 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 pro ecccomppl completion, or submission of <br /> verification that the select material described above will be placed at a minimum of free (5) gallon <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 nlu <br /> re t <br /> �Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />