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BACKFILL EXCAVATION CERTIFICATE <br />/fes!%/ f9/w� �- <br />r, <br />Project Location: — C <br />Owner: /qf„ rt j f�f df S' S Phone No: <br />Contractor: Phone No: L � License No: <br />�/ <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 />—4 A. Pea gravel—smooth, rounded material not more than one-half (1/2) inch in diameter <br />B. Clashed rock--compacting-compacting material not more than three-quarters (3/4) inch in cross sectional <br />measurement. <br />eas rl material and tanks/pipes ed rock will <br />of po not <br />be permits or for <br />bacar materials.) <br />DECLARATION <br />) contact w1PI be made between the <br />bac <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or submissiotank <br />n of <br />verification that the select material described above rrnll be placed at a minimum of five (5) cubic yards per In B2- d Code <br />displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform $ <br />Appendix Chapter 70. <br />c- Z�G,/ <br />ame ( Arlt) <br />It a r1I]t <br />lgnature <br />" Shall be the responsible managing employee on the license or authorized went_ <br />