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\, Noe <br /> BACKFILL <br /> � EXCAVATIONCERRTIFICA�TE <br /> Project Location wt�ST U✓ oIff Fr > q��t ) Co <br /> s <br /> Owner Sff-f k <br /> gcj�M 'l. 01mICT Phone No. ?,n 3?36331Z <br /> Contractor 1�r k 6aSr A one No. ".-7EE License No. bS-7:1]b 6 <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.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavadoa in 12' lifts: <br /> T A. Pea gravel-smooth, rounded material not more than one-half(1/2) inch in diameter <br /> `271B. Crushed rock-self-compacting material not more than threwquarters (3/4) inch in cross sectional <br /> measurement. (Use of crushed rock will not be permined 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 days of pproject 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 /> Aobendix Chanter 70. r y- <br /> A� U <br /> Name nnt) <br /> Itle ( q <br /> Signature <br /> Shall be the responsible managing employee oa the license or authorized agent. <br />