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BACKFILL EXCAVATION CERTIFICA, <br /> Project Location �v LC. //,/-A cy � ?-5 p,.3��l�)2,,, <br /> Owner C I ' Y /r 7_/Q /) C% Phone No.iry(� <br /> Contractor VE Cr r ,CAIV ) ✓ Phone No.2o 1— S�3 0 7S License No. �.SI J`ZJ/—/��h�THA <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> V/'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 permitted for backfill if contact will be made between <br /> the 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 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 /> a E FF cj�OW N� <br /> ame rua <br /> * 129-o3E c'T- tA .4 IUAG.F-f- <br /> u int <br /> * <br /> tgnature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />