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BACICF LL EXCAVATION CERTIFICATE <br />jest Location <br />_ u A Phone No. 1 <br />ver <br />ntractor <br />�e . - Phone License No. % 2 1 <br />INDICATE mETHOD OF BACKFILL QUALITY ASSURANCE- <br />I- <br />SSURANCE <br />L Submission of Soil Engineers Compaction Report within 30 days of project compiedon, or <br />�Z 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 IT lifts: <br />A. pea gravei-smooth. rounded material not more than one-half (12) 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 <br />de of poly resin glass or similar materials.) <br />the backfill material and tanlWPiPes ma <br />DECLARATION <br />ve incation chat the select material desrnbed above will be plat ed at a minimum of five (-) cubic yards per nifc gallon ding <br />erebv certify that a Soil Engineer's Compaction Report will be submitted within 30 days ofproject completion. or submission <br />placement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br />ode Appendix Chapter 70. <br />Shall be the responsible managing employee on the license or authorized agent. <br />