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' BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 10,9 A roCm� UN D ` RAL D ' l , l <br /> Owner U��Vm�t 1� �kE p�I1 E� Phone No. � `f 1 <br /> Contractor Phone No. License No. A§ J 1�b <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 /> ,�CA. Pea gravel--smooth, rounded material not more than one-half(1/2) inch in diameter <br /> S. 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 /> ' 1 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 (S) cubic yards per 1000 gallon tarik <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 /> * T <br /> Name (Print) <br /> it�QE;� <br /> u e (Print) <br /> t nature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />