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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 4025 Coronado Avenue, Stockton, CA 95204 <br /> Owner J.H. Simpson Company Phone No. (209)46b-1477 <br /> Contractor JIM THORPE OIL, INC. Phone No. (209)368-6175 License N0.495699 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> X 2. Submission of verification,e.g., load ticket,within 30 days of project completion that one of the following materials <br /> was placed in the excavation to 12 lifts: <br /> X A. Pea gravel—smooth, rounded material not more than one-half(M) inch In diameter . <br /> _ B. Crushed rock—self-compacting material not more than three-quarters (314) inch in cross sectional <br /> the <br /> mmsureinent. <br /> and tanks/pipes made of pUse of crushed rock will not be oly resin glass or sitted for imilar rr mateif rials will be <br /> made between <br /> DECLARATION <br /> I herchy certify that a Soil Engineer's Compaction Report will be submitted within 30 days ofroject completion,or submission <br /> of verification that the select material described above will be placed at a minimum of five(S�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 <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OIL,INC. <br /> Name (Print) <br /> • CONT (jr 7 <br /> u <br /> sigftwe <br /> • Shall be the responsible managing employee on the license or authorized agent. <br />