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I •BACKFILL EXCAVATION CERTIFICATE• <br />Project Location l �s�O N�tii<i WiL5xJ <br />Owner AvNerM l 6fk __ Phone No. Zd — <br />Contractor SEMCO <br />Phone No. (209) 524-9653 License No. 449864 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. 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 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 />_ B. Crushed rock—self-compacting material nor 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 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days 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 chat the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 70. <br />* e,4fZWH6-Z_ 6_4, voles <br />name (ran) <br />neI [ <br />* � X77( J <br />-5ignamre <br />* Shall be the responsible managing employee on the license or authorized agent. <br />