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&/ BACKFILL EXCAVATION CERTIFICATE <br /> /� <br /> Project Location '41 6 (A <br /> Owner fA6 iQN41 Phone No. � � ' 7© <br /> Contractor POLNI S (, ,�l Phon d Z License No. <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 <br /> was placed in the excavation to 12 lifts: <br /> A. Pea gravel--smooth, rounded material not more than one-half (112) inch in diameter <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 <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I herebv certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion,or submission <br /> of veriftc:ation 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 <br /> Code Appendix Chapter 70. <br /> * <br /> araj nnt) <br /> 1-ale (Print) <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />