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vBACKFILL EXCAVATION CERTIFICATE <br /> Project Location 2L{S L, M wHI(p .pJ k ,,.. 1t-0 a Co1n LVA. , <br /> ril <br /> Owner_ , 1 VV <br /> H. t Phone No. ZOq - qt/l— S36/ <br /> Contractor t 4�a es c u hone No.5300 t.-6, g 14 License No. & 9 7-12 6 yg_ <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.� , load ticket, within 30 days of project completion that one of the following materials was <br /> P in the excavation in 12' lifts: <br /> �A. 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 the <br /> backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> 1 <br /> Lust k t, 4 cite <br /> DECLARATION <br /> I <br /> 1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of pproject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5) 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 /> r <br /> J ame not <br /> [e rmt <br /> "— <br /> Signature <br /> Shall be the responsible managing employee on the license or authorized agent. <br /> i <br /> I <br />