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..L EXCAVATION CERTIFICATE <br /> Project Location D J,7 U <br /> Owner Al\a[,) Phone No. 1 <br /> Contractor �c , N G b N S k -_ Phone No (���- rir)5� License No.-7 3, I _76 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> I. 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 /> A. 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 <br /> the 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 das of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5) cubic 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 /> E <br /> Name (print) <br /> * �o a 12.0; �A AN NC�t_� <br /> 'I IELC <br /> Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />