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4eACKFILL EXCAVATION CERTIFICATE <br /> Project Location 200 N. Beckman Rd. , Lodi, CA 95240 <br /> Owner San Joaquin County Mosquito & Vector ContiPhdne No. (209)982-4675 <br /> Comractor Jim thorpe Oil , Inc. Phone No. (209) 68-6375 License No.4966q�a <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 4 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 1—k 2. Submission of verification, e.gload 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(112) inch in diameter <br /> B. Crushed rock-self-compacting material not more than three-quarters (314) inch in cross sectional <br /> measur=e=.—(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 matenal&.) --- <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 /> * Martin Thor <br /> Name nn[ <br /> * Contractor <br /> re <br /> * <br /> tgnan[re <br /> * Shall be the responsible managing employee on the license or autho agent. <br />