Laserfiche WebLink
Project Location: <br />Owner: <br />Contractor: <br />License No: <br />0 • <br />BACKFILL EXCAVATION CERTIFICATE <br />Phone <br />Phone <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 />_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 />(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 />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(Print) <br />*Title (Print) <br />*Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />