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BACKFILL EXCAVATION CERTIFICATE <br /> Projecll.ocation 3230 N. West Lane,Stoekton, CA 95204 <br /> Owner Van De Pol Enterprises Phone No.y2()c)l4rr c;Qo1 — <br /> Contractor JiM THORPE Q1L 1NC. Phone No. (209)3613-6175 License No.495699 <br /> i <br /> INDICATE ME•1110D OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 2. Suhntlssion 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 /> I <br /> X A. Pea gravel--smooth, rounded material not more than one-half(1/2) inch In diameter <br /> S. Crushed rock--self-compactingg material not more than three-quarters (3/4) Inch in cross sectional <br /> measurement. (Use of cruslued rock will not be Permitted fair backfill if contact will be made between <br /> Ute backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I berchy(:CT Iffy that a Coil Fmgincer's Compaction Report will be submittcd within 30'd' of «eject completion,or submission <br /> of vel ificnllon tits( the.select ntnterini described above will be placed at a minimum of five(S�cubie yards per IOW gallon lank <br /> displacement and (hat ithe entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OILtINC. <br /> Name tint <br /> • CUN'I'R R <br /> it a nt <br /> R <br /> Signa re <br /> Shall be the responsible managing employee on the license or authorized agent. <br /> i <br /> i <br /> i <br />