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BACKFILL EXCAVATION CERTIFICATE <br />Project Location <br />n _ :;;; ; c, <br />Z�JI ILP�tY7 Phone No. Z O y�S /5 -5'3 <br />Owner <br />Contractor9F_ <br />'' I t`L 4 Phone No ._� "G0 7 y<�Lo3 License No. g3 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />Vl. 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 in 12" lifts: <br />_ A. Pea gravel --smooth, rounded material not more than one-half (1/L) inch in diameter <br />B. Crushed rock--self-compacting material not more than three-quarters (3/4) 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 herertb�y certify that a Soil Engineers Compaction Report will be submitted within 30 dam Of❑]'s of roject completion, or submission <br />dof isplacement and that select <br />l ct matntire erial <br />a described <br />bedwilabove backfilled I be and ompactat a ed to insure compliance cubicwith the Uner iform Building <br />Code Appendix Chapter 70. <br />ame nnq <br />LLIC nn <br />atgnature <br />+ Shall be the responsible managing employee on the license or authorized agent. <br />