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BACKFILL EXCAVATION CERTIFICATE <br />Project Location The Pott of Stockton, 2201 W. Washington St., Stockton, CA 95203 <br />Owner Same as above Phone No.,(( 209) 946-0246 - <br />Contractor JIM THORPE OIL.- INC. Phone No. (209)368--6175 License N0.495699 <br />INDICATE ME '11013 OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />2. Submission of vetification, e.., 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/r2) Inch in diameter <br />Crushed rock- -seff- cow pacting material not more than three-quarters (3/4) inch in cross sectional <br />measurenicni. (Use of <br />material and tanks/pipes srock will madeot be f polyrresindfor glassbor similar materialsbe made between <br />) <br />— B <br />DECLARATION <br />I hereby certify that a Soll Engineer's Compaction Report will be submitted within 30 days of project completion, or submission <br />of verificatlon that the select material described above will be placed at a minimum or five (5) cubic yards per 1000 gallon lank <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 />• JIM THORPE OIL,INC. <br />Name (Print <br />• Shall be the responsible managing employee on the license or authorized agent. <br />