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OKFILL EXCAVATION CERTIFICATE a <br />Project Location 17-6b bi <br />Owner Z � AW Phone No. 7 <br />Contractor�� f/� Phone No 7—le o� License No. le�ZZ <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.p., 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 (112) inch in diameter <br />B. Crushed rock--self-compacting material not more than three-quarters (314) 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 that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 70. <br />QS02--T Name (Frint) <br />[t <br />hw vv <br />1 <br />* Shall be the responsible managing employee on the license or authorized agent. <br />