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02/01/2006 17:21 FAX 510 611 9396 PARADISO MECHANICAL Z021 <br /> R; <br /> _ BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: <br /> Owner: Phone No: b• G�3 <br /> Contractor-Pis�ntsb MTicliJwra�t ►4e _ PhoneNo:61D- X14-B39b _ LicenseNo:G779 D9 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ <br /> I- Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> -4 2. Submi <br /> placed in the excavation 5ion of n Ie.F., load ticket, within 30 days of project completion that one of the following materials was <br /> A_ Pea gravel--smooth,rounded material not more than one-half(1/2)inch to diameter <br /> _ B. Crushed rock—self-compacting material not more than three-quarters (3/4) inch in cross sectional <br /> backfiit�tnateria�and otnnkksJpipcsrock will not mad of polyresin glass or tted similar backfill <br /> matenats.j et will be made between the <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of rojec completion,�0submission noof <br /> verification that the select material described above will be placed at a minimum of five ( gallon <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance withtheUniform Building Code <br /> Appendix Chapter 70. <br /> time tint <br /> e nn <br /> t <br /> + t <br /> • Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 10/16/03) Page 11 <br />