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MAR. 1$. 2005 3:44PM- C RD BLDG SVCS NO. 0495 P. 6 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: Ao4Q1 T Cfa"�jT�1 <br /> Owner_ Phone No: 7 rhe -q4 JG(p <br /> Contractor: l Phone\To: 516_ License No:___Co` <br /> INDICATF METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil E%incet's Compaction Report within 30 days of project completion,or <br /> L/ 2. Submission of verification, e.tr 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(1/2)inch in diameter <br /> E, Crushed rock--self-compacting material not more than three-quarters (3/4) inch in crass 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 /> NG CE ; &s'[' k\ CIF eX(Amb M Ors )N kt_- t'F- TW_4—r--r- ZM L <br /> Lapw Z 3 crF C�F-�,7tU t��4 W lL�ME L.LF_'D W lT� <br /> �AMP�ECLAR f10N "gf C FL1�'r�FAC W C Sf!]EF.f�1 <br /> 1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 da s 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 Uf form Building Code <br /> Appendix Chapter 70. <br /> .Name t) <br /> QT'S lr a Fr! t) <br /> Sana re <br /> Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 10116103) Page t I <br />