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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: ST.- <br /> Owner - <br /> Owner:S: u Phone No: 2407- VTCZ 26<� <br /> Contract �Jsr Fe ��,�� Phone No:� -� &3YL,3 <br /> License No_� (,c s — � <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 /> of pproject completion, or submission of verification that the select material described above <br /> wilhaltbhplaced firat <br /> will be of backfllec and compac ed0toansure comp iiancemwith and <br /> the <br /> Uniform Building Code Appendix Chapter 70. <br /> Mime rin <br /> i e nn <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />