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i <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project laxation 25433 Rmice Rd. , Acanm, CA 95220 <br /> Owner lbP Fannie Mao Frnmdstinn Phone No. (2n9)235-9.02n <br /> Confrnclor JIM 11IORPE OIL, INC. Phone No. (209)368-6175 License No.495699 <br /> i <br /> INDICATE METI IOU OP BACKFILL QUALITY ASSURANCE <br /> 1. Subrrtlsslon of Still Engineer's Compaction Report within 30 days of project completion, or <br /> x 2. Submisslon of veliRcation, e.RR., load ticket, within 30 days of project completion flint one of the following materials <br /> was placed In lire excavation in 12' lifts: <br /> X A. Pea gravel--smooth, rounded material not more than one-half(1/2) Inch In diameter <br /> B. Crushed rock--self compacting materint not more than dicee-quarters (3/4) Inch In cross sectional <br /> mensnremeut. (Use of crushed rock will not he permitted for backfill If contact will be made between <br /> lite backfill material and ,rinks/pipes made of poly resin glass or similar materials.) <br /> DECLARA'T'ION <br /> 1 botchyy(citify Ihnt n Soll Engineer's Compnction Report will he submitted within 30dayt of niject completlon or submission <br /> of verincation that the select mnlerial described above will be placed at n mininumt of five (5�cublcyards per RW gallon lank <br /> displacement and ,lint the entire excavation will be backfilled mid compacted a) Insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> • JIM 1110RPE OIL,INC. <br /> Name (Print) <br /> • (�N'I'Itll I <br /> ie rn <br /> rinture <br /> Shrill be live responsible managing empioyre on the license or nutitorized agent. <br /> I <br /> I <br /> i <br /> I <br /> ' I <br /> I , <br />