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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location:.N.,E- /orwer &W g1,47 E•f�Hi��w���Li'lWeA C4-- '9 Xa3G <br /> Owner CAI 7.PAW5, ('A- �fnfy 7/anso.r7�•7f/an Phone No4S:1-241 yys'-G37� <br /> Contractor: Geoca� �onr�/�•ef; 1nf. Phone No/.9 Sat 4iia <br /> License No: 7/6OW <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 /> _,X 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 /> Sand S4, �rj, Cmncrc-le <br /> � <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 f M_ <br /> rent <br /> Title Conl�r4•�.a� .�ryifrf NGR - Rr%L= %c-(mn�fmc f•� <br /> nn <br /> Signatures �h <br /> *Shall be the responsible managing employee on the license or authorized agent. <br />