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rr+ac 1G <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location-.. <br />Owner:�� J T C��� /iUC, ' /Phone No: <br />Contractor. a/�,(& Q/� Phone No; <br />License No: 2 Z-6 P g <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Sail Engineer's Compactlon Report within 30 days of project <br />completion, or <br />_ 2. Submission of verification, e.g., bad ticket, within 30 days of project completion that <br />one of the following materials was placed in the excavation in 12" lifts: <br />'Z!L�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 />riot inch in cross sectional measurement. (Use of crushed rock will <br />not a 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 />ohereby <br />pr ject completion, oroslubmission �og)�f OMTacton Report <br />select submatermitted <br />d pworm 3 adave <br />thaltbthe (entire excavation will beat a minimum of vbackfilled and CompactedOtoailnsure Compliaanccemwith the <br />Undorm Building Code Appendix Chapter 70. <br />-, � 0 r V/G /("� /Co17� <br />Shall be the responsible managing employee on the license or authorized agent. <br />