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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location Z21 6 <br /> I' ✓ ��. �t �JUtn t <br /> lO <br /> Owner iA v�1 et/4— ;4-ee( Phone No( 70c) �7-_/—b 1 q7 <br /> Contractor s121C0 Phone No. (209) 524-9653 License No. 449064 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 4L 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 /> X 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 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. <br /> J(te L. etc <br /> Name rtnc <br /> Wert) � <br /> W <br /> signature <br /> • Shall be the responsible managing employee on the license or authorized agent. <br />