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i <br /> I. ?k <br /> EI <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Ij <br /> Prole Location �' oc <br /> Owner Phone No. a�CFt- 5 3�5 - ct I I C� <br /> ContractorLic:��: lone No_ > - �S3.3� Gr?. License No. <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> r <br /> _ 1. Submission of Sail Engineer's Compaction Report within 30 days of project completion, or <br /> f <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12" lifts: i <br /> A. Pea gravel—smooth, rounded material not more than gone-half(112) inch in diameter <br /> B. Crushed rock--self-compacting material not more ,[hap rh=-quarters (314) 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 ;lass or similar materials-) <br /> II <br /> f <br /> DECLARATION ! <br /> .i <br /> `i <br /> I hereby certifv that a Soil Engineer's Compaction Report will be submined-within 30 days ofprvje� completion, or submission of <br /> verification that the select marenal described above will be placed at a minimum of nve (5) cubic yams per 1000 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to',insure compliancz with the Uniform Building Code <br /> Appendix Chapter 70. <br /> * L~V 1. <br /> time ( t) <br /> * _ ;r'�-e <br /> i e t Pnnt) <br /> Signature <br /> Ef <br /> * Shah be the responsible managing employer on the license or authorized ag E L. <br /> Er <br /> IIS <br /> .F <br /> I I <br /> �f5 <br /> i4 <br /> E� <br /> I` <br /> t� <br /> • ih <br /> jY I. <br /> •i <br /> ti <br /> 'i <br />