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t rrBACKFILL EXCAVATION CERTIFICATE <br /> Project Location: Vl V o Iy. w 1 hun WA\1 i s t Cpbt, <br /> Owner hf* C(,'111 fby h* G1 EVS , LID Phone No:c�5P2 6121 -� <br /> Contractor: 'rf l ��F� �. } S��Urr G��A C Phone No:6)() 6) ( G O(P 10�2Z <br /> License No: <br /> / INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> V 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> one of the following materials was placed in the excavation in 12" lifts: <br /> A. Pea gravel--smooth, rounded material not more than one-half (1/2) <br /> inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quarters <br /> (3/4)) inch in cross sectional measurement. (Use of crushed rock will <br /> 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 <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> of project completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> *Name �� t� T dbl C <br /> nn p.. <br /> Title IY Q � � 1_"� AI N V1 1 A�uxT6 <br /> rin <br /> Signature e117 t <br /> "Shall be the responsible managing employee on the license or authorized agent. <br />