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BACKFILL EXCAVATION CERTIFICATE <br /> Hutchins Street Square <br /> Project Location 209)333-6800 <br /> The City of Lodi / Public Works Dept. Phone NO. ( <br /> Owner <br /> Contractor JIM THORPE OIL, INC. Phone No. (209)368-6175 License No.495699 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ L Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 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 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 /> tmesuremet. (Use of hea <br /> backfillnmaterial and talnks/pipes made of polyrresiittn glassfor bor similackrill ar materials.)f contact bemade between <br /> DECLARATION <br /> I betel99 certify lhnt a Soil Engineer's Compaction Report will be submitted within 30 days of rojecl completion,or submission <br /> of vetlflcallon that the select material described above will he 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 <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OIL,INC. <br /> eme r nt <br /> • CON'PRACT - <br /> ue rn <br /> gnature <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />