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KFILL VATION CERTIFICATE <br /> Project Location S *N ryqsr <br /> q <br /> Owner "f'?.><-- f1 _` 5 2{C1 Phone No.- <br /> ontractorAdl,}}(ICC,L_C C-b �pLlt1+L� Phone No. 2?�9 q67 J M License No. <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 not more than three-quavers (314) inch in cross sectional <br /> measurement. (Use of crushed rock will not be per=tted for backfill if contact will be made between <br /> the backfill material and tanks/pipes mad of poly resin glass or similar materials.) <br /> a5T �f m =. <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 /> * 1 AtkJ 44 ` `� <br /> Name ( rmt) <br /> it e ( rtnt) <br /> f I �� <br /> * 1 , 6 <br /> ature ` <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />