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OKFILL EXCAVATION CERTIFICATE • <br /> Project Location_] bppp l ffleml U Nb ICsCW— D " <br /> Owner r <br /> f T4 <br /> Phone No. <br /> Contractor -DELI - <br /> Phone No. License No.—A W Wb <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 /> B. Crushed rock--self-compacting material not more than three-quarters (3/4) 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 da s of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of f�ve ( ) 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 /> ame t nt <br /> u�1�J�� <br /> I <br /> it a Print) <br /> nature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />