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• • <br /> BACKFILL EXCAVATION CERTIFICATE <br /> i <br /> project Location 3230 N. West Lane , Stockton , CA 95204 <br /> Owner Van De Pol Fnterr7ri aeS <br /> (hone No. (^n n) n c r_ Fnn1 — <br /> Conitnctor JIM THORPE OIL, INC. Phone No. (209)364-6175 License No.495699 <br /> INDICNI'E MF I'IIOD OF BACKFILL QUALITY ASSURANCE <br /> L Subudsslon of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 2. Suhnllsslon of verl0c�fion, e.q., 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 gmaterial not more than one-half(1/2) Inch In diameter <br /> ross <br /> B meas"IculeuCrushed k. (Use of crushed rocksrial not ill tool helre than per Witted Ifor backfill If cuatters ontact willibecmade between <br /> file backfill material and tankslpilies made of poly reshn glass or similar materials.) <br /> DECLARATION <br /> I brrcly(etlify that a Soll Fnglaeet's Compaction Report will be subndtted within 30 days of roject completion,or submission <br /> of veli catlon that the select mnlerial desctiberl above will be placed at a ndninrull of five (S�cubic yards per 1000 gallon lank <br /> dlsplaccmetu and that the entire excavalion will be backfilled and compacted to Insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OIL,INC. <br /> ante r nt <br /> ' CONTH R <br /> tite7P-"m <br /> Igna re <br /> Shall be file responsible managing employee on the license or authorized agent. <br /> i <br /> I <br /> i <br /> i <br />