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rKum P 1 d <br /> BAC\�K-FU-L�EXCAVATION CERTIFICATE <br /> Project Location 3^'v i L-�N+J C� �U <br /> Owns Phone No. ?n-3,31t 331N <br /> Contractor N 1 Phone No. g��� License No. 6S)3kJ0 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> I. Submission of Soil Engineer's Compaction Repon within 30 days of project completion, or <br /> 2. Submission of verification, e.g-, load 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 /> Zl B. Crushed rock—self-compacting material Dot «tore tban three-quarurs (3/4) inch in cross sectional <br /> measurement. (Use of crushed rock will trot be permitted for bacifiill 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 days of pproject completion, or submission of <br /> venfication tbat the select material described above will be placed at a minimum of five (S) cubic yards per 1000 gallon tank <br /> displacemew and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br /> Appendix Chapter 70. <br /> /N�atme nnt) <br /> • .,1` ��tG.1 W�L�It-N"`LJ l" i1' � l .�b� <br /> lIe L <br /> l NIC <br /> • Shall be the responsible managing empioyee on the license or authorized agent. <br />