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P' "KFILL EXCAVATION CERTIFICATE <br /> Project Location U t L <br /> OwnerPhone No. —7 <br /> ContractorJN G> i Phone No =1��— rit)ra'y License No.-7 Z <br /> N : I 1 0 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 2. Submission of verification, e.3load 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(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 <br /> the 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 /> •� � r^ (� f� C-�E <br /> ante <br /> • P iso ECM A P�Cc�Z <br /> Title i <br /> .� P <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />