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7�anIR SAN .IOAOUIN COUNT <br /> r' t COMMUNITY UEVELOPj'n''NT UEPANTMENT <br /> 1610 E n"FLIOn AVE.510000N.G 95205 <br /> �tl013A O"torMEFn SEMACES P11011E 12091 5663120 <br /> N APPI 1O r11@IF 12011 49R 1170 <br /> m1 WO ruCRIF!12091 4963123 <br /> nFIG1690MIOM PnESEMIABOu VnOuF-12091 4663021 <br /> UACRFILL EXCAVATION CERTIFICATE <br /> Project Location 900 1/2 E. Victor Rd. Lodi, CA 95240 <br /> Owner Teresi Trucking Phone No. (209)368-2472 <br /> Contractor Jim Thorpe Oil, Inc. Phone No. (209)368-6175 License No. 495699 <br /> IRDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1 . Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> X 2. Submission of verification, e.g. load ticket, within 30 days of project <br /> completion that one of the following materials was placed In the excavation in <br /> 12" lifter <br /> X_ A. Pea gravel - smooth, rounded material not more than one-half (1/2) <br /> Inch in diameter. <br /> Crushed rock - self-compacting material not more than three-quarters <br /> (3/4) inch In cross sectional measurement. (use of crushed rock <br /> will not be permitted for backfill if contact will be made between I <br /> the backfill material and tanks/pipes made of poly resin glass or ' <br /> similar materials. ) <br /> DECLARATION <br /> 11lereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> Of project completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> * Jim Thorpe Oil, Inc. dba Rich-Mart Construction <br /> Name (Print) <br /> Contractor <br /> '1'itl (P ' lit <br /> * il- _ President <br /> ignature <br /> * Shall be the responsible managing employee on the license or authorized <br /> agent . <br /> 6/9l-LC/0ECERT.OoC <br />