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BACKFILL EXCAVATION CERTIFICATE <br /> ProjectLocation:^/. c <br /> Owner CAL7PANS ��r m� { �ra�co �f �f/a„ Phone No:/�-S-,? <br /> Contractor(jeoco� to r //117f ZAe Phone No:-4 85 4iid <br /> _. License No:�6t2c -A s�,4z 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 be 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 /> LSC_ a Samek Sa c/ s%.may �o < «fe> <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 le-le. 7` moi.. <br /> _ -mint <br /> Title toAstr..,f u, Ce,- /o.r f*r 7f r <br /> nnc) <br /> Signatures �z <br /> 'Shall be the responsible managing employee on the license or authorized agent. <br />