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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 76' E. Hazelton St. , Stockton, CA 95203 <br /> Owner <br /> Zoya 0. Bryner Phone No. N/A <br /> Contractor Jim Thorpe Oil, Inc. Phone No.(209)368-6175 LicenseNo495699 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> X 2. Submission of verification, e.g-, load ticket, with"m30 days of project completion that one of the following materials was <br /> placed in the excavation in 12" lifts: <br /> X 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 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 da s of project 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 /> * Jim Thorpe Oil, Inc. by Richard Thorpe <br /> ame rmt) <br /> * Cot ct r/ resident <br /> t[e( n <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />