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y <br /> BACKFILL EXCAVATION CER'T'IFICATE <br /> --fl- <br /> Project Location ✓1 L�rl i-L4n +�+°f.M�.e-ya_U.3 �A <br /> Owner_ (_2Ur9_J��M A 4— 0--g _ Phone No <br /> Contractor cv Phone No°l((, License No f �� <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 <br /> was placed in the excavation in 12 lifts <br /> k A. Pea gravel--smooth, rounded material not more than one-Half(1/2) inch in diameter <br /> B Crushed rack--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 <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 da of roject completion,or submission <br /> of verification that the select material described above will be placed at a minimum of five: (W 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 <br />• Code Appendix Chapter 70. <br /> ame (Print) <br /> nature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />