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06/14/2004 16:39 2094671110 AGE STOCKTON PAGE 06/06 <br /> ^� ^ '-$BACKFILL EXCAVATION CERTIFICATE <br /> Project Location <br /> Owner Pham No. ZVq 14"3 — zOO¢ <br /> contractor-d CiP��ererJagwlahoae No.�ZOR1a License No. &8027- <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 74 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(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 got be permitted for backfill if contact will he 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 withia 30 da of pproject completion, or submission of <br /> verification that the select material described above will be placed at a minimi of five (S) cubic yards per 1000 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insttre compliance with the Uniform Building Code <br /> Appendix Chapter 70. <br /> ame (Frmt <br /> STAFF G E0 0uLl S <br /> 7- <br /> tie (Print) <br /> nt o <br /> Shall be the responsible managing employee on the license or autborized agent. <br />