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BACKFILL EXCAVATION CERTIFICATE (� <br /> Project Location_S( Ll <br /> Owner S*, nyj,� l4c� 5--V-C,2e)1 Phone No. 004 -CJ9'7- 33Wr7 <br /> Contractor t3�:�� � tcm me Phone No. 06�-�-to rj! License No. (ate I c <br /> Cc-esl . <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 2Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> . Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the evon in 12" lifts: <br /> d A. Peaatigravel—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 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 /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of pproject 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. tt <br /> am t <br /> * pSr2.S` <br /> t e tint <br /> * <br /> signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />