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04/02/2001 10:31 209 3433 FIFTH FLOOR PAGE 12 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location Amo <br /> �1 0i 0—a `` <br /> Owner /A-L n r,' -1 PhoneyyNo.�10 &70-53p <br /> Contractor V �(j (4i a /^nn iL4;&)4ne No.(JV;S) Q -Q n License No.. (fin <br /> 14- D . <br /> INDICATE METHOD 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 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. Crusbed rock-self-compacting material not more than three-quarters (314) inch in cross sectional <br /> measurement. (Use of crashed 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 sub ' sion of <br /> verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000 all n tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Buil g Code <br /> Appendix Chapter 70. <br /> ame nt <br /> S�„fDe�v <br /> eignait e t <br /> ture <br /> " Shall be the responsible managing employee on the license or authorized agent_ <br />