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s <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Location 4025 Coronado Avenue, Stockton, CA 95204 <br /> Project � <br /> Owner J.H. Simpson Company Phone No. (209)466-1477 <br /> Contractor JIM THORPE OIL, INC. Phone No. (209)368-6175 License N0.495699 <br /> I <br /> INDICATE METtIOD OF BACKFILL QUALITY ASSURANCE <br /> i <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 In 12" lifts: <br /> X A. Pea gravel--smooth, rounded material not more than one-half(1/2) inch in diameter . <br /> B. Crushed rock--seir-compectinit 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 /> tate backfill material and tanks/pips made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I herchyy certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion,or submission <br /> ank <br /> displacementof rthat the and that tate entire excavalect material tion will bcribed e�b backfilled ve will be and compaclaced at a tedmum or o insure Rcomliance with thards e Uniform <br /> Building <br /> Appendix Chapter 70. <br /> �+ it <br /> • JIM 111ORPE OIL,INC. <br /> Name (Print) <br /> • CONT <br /> t <br /> -17 <br /> Sigitmote <br /> • Shall be the responsible managing employee on lite license or authorized agent. <br /> i <br /> i <br /> i <br />