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CKFILL EXCAVATION CERTIFICATE <br /> Project LocationV't+�a "t <br /> Owner Phone No. 7 <br /> Contractor STS a Hca Phone No. T-Oq-g12ti 3 License No. �?,n C(/0 - — <br /> er.:� 1`�,�.,Cry• •--F��. <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. ., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12' lifts: <br /> 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 /> Name rent <br /> tt a rent <br /> I ture <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />