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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 311­7 Fp_c_m ) T S etre / -- <br /> Owner �M� 1 U-f Ak/J)L{S 1� Phone No. Z 0� 3 — Zoo4- <br /> Contractortx�b�Jrretjnw��� hone No. (Z( 461 -1206 License No. 690 ZZ <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 7)4 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 life: <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 [Wade 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 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 Con 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 /> Y I/vII MLIc Aa�C, N <br /> ame not <br /> -5-rAFF &.rola �i' S F <br /> I e Frmt <br /> � e / <br /> USignature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />