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0 9 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location: /5.33 F�sT c9. <br />Owner EZ21 /1G.%GW11_15;/'0yA7ixflhone No: Xi'7- 506 -SO/9 <br />Contractor: e1ZI-JC- Phone No: 2-09 36�G/75 <br />License No: % 5 6 l7 Cl <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1 ` ubmission of Soil Engineer's Compaction Report within 30 days of project <br />completion, or <br />Submission of verification, e.g., load ticket, within 30 days of project completion that <br />one of the following materials was placed in the excavation in 12" lifts: <br />% 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 />(3/4) 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 />I hereby certify that a Soil Engineers Compaction Report will be submitted within 30 days <br />ofProject completion, or submission of verification that the select material described above <br />will be placed at a minimum of five(5) cubic yards per 1000 gallon tank displacement and <br />that the entire excavation will be backfilled and compacted to insure compliance with the <br />Uniform Building Code Appendix Chapter 70. <br />'Name D,9'v e�L <br />MR) <br />Title <br />'Shall be the responsible managing employee on the license or authorized agent. <br />