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CKFILL EXCAVATION CERTIFICATE <br /> Project Location ' ` ' ! <br /> OwnerI'll 11 - e__ <br /> Phone Na. <br /> Contractor��n1�1�3�r-b -- <br /> Phone No. dd� ��'i/`'�License No. <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 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 excavation in 12" lifts: <br /> _ A. Pea gravel--smooth, rounded material not more than one-half(112) inch in diameter 4 <br /> B. Crushed rock--self-compacting material not more than three-quarters (314) inch in cross sectional <br /> measurement. (Use of crushed rock will not be permitted 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 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. ,r ' <br /> 'ie rmt <br /> * �cS <br /> it a rant <br /> * <br /> gn <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />