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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location Dc <br /> Phone Yo. 9 3 <br /> 5�-- /91$ <br /> Owner - n 014s /� �G� o.-i� — J <br /> Contractor�{�{ m4 0��sf`D �A/t t��o Phone No. To P — (t a6 License No. �P� ZZ� <br /> INDICATE METHOD OF BACKFILL QUALITY ASSU'PANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> ,,*�2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in l2" lifts: <br /> _✓A. Pea gravel—smooth, rounded material not more than one-half(112) inch in diameter <br /> B. Crushed rock—self-compacting mzterial not more than thrr-quare s (3/4) inch in cross se_:ional <br /> measurement. (Use of crushed rock will not be permined for bactmll if contact will be made between the <br /> bark511 material and tanksipipes made of poly resin lass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compac• on Reuor will be submitted within 30 days of project completion, or submission of <br /> verification that the select material dumbed above ;will be placed at a minimum of rive (5} cubic yards per 1000 alloa tank <br /> displacement and that the entire excavation will be backfilled and compac:ed to insure compliance with the Umtorn Building Code <br /> Appendix Chapter 70. <br /> ., am�e lP iat) - <br /> twe�.ntZ <br /> Jtenattue <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />