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001i;6A�i <br /> SAN JOANUIN ANTYCOMMUNITY UEVEI.OPMFNT UEPANTMEN7 <br /> +� 1610 E ItAIE,11011 AVE.SIOCKIOO.CA 95705 <br /> OEVEI.OrMEOT SERACES MotF_'17091 166 3120 <br /> rINAAna 1`1101IE:12091 469311.0 <br /> BUIO01B PI"IE:(7091 /663171 <br /> TIE Aii lnOftl K)OO fRESEIIVAII011 I'llOnE:12091 466 3071 <br /> UACKFILL EXCAVATION CERTIFICATE <br /> Project Locatlon 7850 N. West Lane Stockton, CA 95210 <br /> Owner Golfland Arcade Phone No. (209)477-2424 <br /> ConLracLor Jim 'Thorpe Oil, Inc. phone No. (209)368-6175 License No. 495699 <br /> INDICATE NETOOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1 . Submisston of Soil Engineer's Compaction Report within JO days of project <br /> completion, or <br /> _--X 7. . submisslon 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" llftet <br /> --IF- A. pea gravel - nmooth, rounded material not more than one-half (1/2) <br /> Inch in diameter. <br /> _ B. Crushed rock - eelf-compacting material not more than three-quarters <br /> (3/4) inch to cross sectional measurement. (Use of crushed rock <br /> will not be permitted for, backfill if contact will be made between <br /> the backflll material and tanks/pipes made of poly resin glass or ' <br /> similar materials. ) <br /> DECLARATIOII <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> of project completion, or submissl.on of verification that the select material described above <br /> �l.tl be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> khat the entire excavation will be backfilled and compacted to Insure compliance with the <br /> Jnlform Building Code Appendix chapter 70. <br /> Jim Thorpe Oil, Inc./Contractor <br /> Richard Thor e <br /> Mame (Pr nL) <br /> President <br /> — (Print:) <br /> Signature <br /> Shall be the responsible managing employee on the license or authorized <br /> agent . <br /> /9l-Lc/BecenT.Doc <br />