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Aug -30-04 04:23pm From-Gettler-Ryan Inc <br />+9166311317 T-351 P-003/005 F-255 <br />Project Location: 5;9&/_5_z,,6 0e_oo Z oW b <br />Owner.:) <Fe_e 45/L �c7S _ -Phone No: 9/6, CRe- Z S <br />Contractor:'14e41e�,ro hg:e_ 'Y'am'604 ,LNG Phone No:S/�, /��''.�9a License No: C X 90 9 <br />INDICATE NIETHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />2. Submission of verification, e.Fz 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 the <br />backfill material and tanks/pipes made of poly resin glass or similar materials.) <br />DECLARATION <br />1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of roject completion, or submission of <br />verification that the select material described above will be placed at a milaimum 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 />s 7,1 L T/i- 1'2h D�s� <br />ame (mnt) <br />to t <br />w <br />* Shall be the responsible managing employee on the license or authorized agent <br />E14 23 046 (Revised 10/16/03) Page I 1 <br />