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Project Location_ <br />CKFILL EXCAVATION CERTIFICATE <br />11tH —7ZAt,J <br />Owner 1�t6 CA4__) aZ0Dr_, 041 Phone No. L7L` <br />Contractor SEMOO Phone No. ( 209) 524-9653 License No. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />449864 <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 12" lifts: <br />A. Pea gravel --smooth, rounded material not more than one-half (112) inch in diameter <br />B. Crushed rock—self-compacting material not more than three-quarters (314) 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 />C�XL- Ak_ TA,"tc 1s Loco J%4 fpLp, ve.AVfJ_ nr TLMYk&-4, Rsr- <br />REOV&t_ TldL ExtsrC1 lt ILAen<ciw ydt�t &$— Mt'— e�L{}CiiCJ ttsro ri*e_ G^:. AeATIQ-� <br />Pee171.kG I_iWFh't- 610'p}"gCLARATION <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 andcompacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 70. <br />Name (Yrmt) <br />e q <br />Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />