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r BACKFILL EXCAVATION CERTIFICATE <br /> p.oject Location Phone No. <br /> Owner /�r7 C�/—] �� _License No. - � <br /> Phone No. <br /> Contractor <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Comp <br /> action Report within 30 days of project completion, or <br /> ' Ian of verification, e. load ticket, within 30 days of project completion that one of the following materials was <br /> 2. Submission <br /> placed in the excavation in 1a' lifts: inch in diameter <br /> A. Pea gravel--smooth, rounded material not more than <br /> otnheanalthree-quarters <br /> ree quarters {314) inch in cross sectional <br /> B Crushed rock--self-cornpactirig maters errnitted for backfill if contact will be made between the <br /> measurement. {Use of cnished rock will not he p <br /> backfill material and tankslpipes made of poly resin glass or similar materials.} <br /> DECLARATION <br /> on of <br /> be the cubic ands per 1000 gallon tank <br /> certify that a Soil Engineer's <br /> compaction Reportwl be will <br /> placed attta rn m of days <br /> of Compliance with the Utriform Buildings Code <br /> I hereby c Y <br /> verification that the select material described a <br /> displacement and eC�©the entire excavation will be backfilled and compacted to insure comp <br /> Appendix Chapter <br /> Name risit <br /> t e rint <br /> ignature <br /> I <br /> X <br /> " Shall be the responsible managing employee on the license or authorized agent. <br /> T . <br /> 2. I <br /> I <br /> NC i <br /> I <br /> 1CC <br /> J <br />