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0 0 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location: 574_x -e7 <br />Owner 7e- ZZACO /1J6. No: 3`f7- >0'6,56151 <br />Contractor: in% // ,2104 Jil /-JC. Phone No: 2.0) 3i.PG/75' <br />License No: -174 g5 6 I % <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br />completion, or <br />2. 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 Engineer's Compaction Report will be submitted within 30 days <br />of project 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,,g•l/g�L J. 4),1e/06iZ <br />Print) <br />Title <br />Print) <br />Signature'v <br />*Shall be the responsible managing employee on the license or authorized agent. <br />