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BACKFILL EXCAVATION CERTIFICATE <br />Project Location � ©1 F7,qc5-r Cf � Wd <br />Owner d \ Y` !J Phone No. /- tij-� —�3M <br />Contractors' jDk U ( (fe A-, -17 "�Q U cT;Phone No._ZQ� q 3 z Sp i'z License No. 2'? <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.g., load ticket, within 30 days of project completion that one of the following materials was <br />placed in the excavation in 12" lifts: <br />_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 />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (5cubic 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 />Name (Fant) <br />*,r,,- S <br />- - Tit a Tint <br />* Shall be the responsible managing employee on the license or authorized agent. <br />