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KFILL EXCAVATION CERTIFICATE* <br /> Project Location <br /> Phone No. <br /> Owner <br /> Contractor Phone No. License No. <br /> INDICATE METHOD 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.g.; 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(112) inch in diameter <br /> _ B. Crushed rock—self-compacting material not more than three-quarters (3/4) inch in cross sectional <br /> ackfill if contact <br /> the backfillnmaterial and tanks/pipes made of poly t. (Use of crushed rock will not be sresin glass or rmitted for similarr materials.)will be made between <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submined within 30 days of pproject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five ian cubic yards per m B ,ganon 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 /> ame rm[ <br /> nit e rmt <br /> ignamre <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> WI� <br />