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BACKFII.L EXCAVATION CERTIFICATE <br />Project Locition <br />V �`` P/hone No. 1/0 <br />Owner <br />Contractor W V IC �� Phone No233 t)2S-License No. (n S/ 1 <br />INDICATE N=OD OF BACKFILL QUALITY ASSURANCE <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 <br />was placed in the excavation m 12" lifts: <br />A. Pea gravel—smooth, rounded material not more than one-half (12) 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 <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 project completion, or submission <br />of verification that the select material described above will be placed at a minimum of five (: ) cubic vards per 1000 gallon tank <br />displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br />Code Appendix Chapter 70. <br />Shall be the responsible managing employee on the license or authorized agent. <br />