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BACKFILL EXCAVATION CERTIFICATE <br /> L I <br /> PtojectLocadon Star Buildi S stems 12101 E. Brandt Rd. , Lockeford(2o9)92735504 II <br /> Owner Star Buildi S stems <br /> Phone No. <br /> Contractor JIM THORPE OIL INC. Phone No. (2091368-6175 License No.495699 <br /> - I <br /> INDICAI•E METHOD OF BACKFILL QUALITY ASSURANCE <br /> letion,or <br /> L Subotission of Soll Engineer's Coutpaction Report <br /> within 30 Jays oproject <br /> ome letion that one of the following materials <br /> X 2. Subnrissbtn of verincation, c-Z, load ticket, within 30 days of projectp <br /> was placed In the excavation in I2" lifts: <br /> X A. Pea gravel--smooth, rounded Rmaterial not more than one-half(i/2) Inch in diameter . <br /> uArtets <br /> Inch in <br /> ross <br /> B. Ce `iremenk. (Use of err Shed o-k will not be permitted Material not mote than lfor backfill If contact will be made betty en <br /> lite backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> mat <br /> ii <br /> it <br /> DECLARATION <br /> 1 hetehqq certify that a Still Engineer's Compaclioa Report will be submitted within 30 days of rojeci completion,or submission <br /> of verilication that the select material described above will be placed at a mbtimum of bve(5�cubic yards per Uniform <br /> gallon dank <br /> displacement and dmt the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. j <br /> I <br /> I <br /> • JIM 1'11ORPC OIL,INC. I <br /> ame ( r nt I <br /> i <br /> • CON'' R rile n <br /> ignatur <br /> r Shall he the responsible managing employee on the license or authorized agent. it <br /> i <br /> I <br /> i <br /> I <br /> II <br /> (I <br /> i <br /> I ' <br /> it <br />