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I <br /> CKFILL EXCAVATION CERTIFICATE ) <br /> v � <br /> Project Location n (� <br /> wC Phone No. <br /> ownerA <br /> Phone NLicense No: <br /> Contractor <br /> INDICATE METHOD OF BACKFILL QUALITY.ASSURANCE <br /> Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> �. 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(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 <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 days of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum 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 /> Name rent <br /> * <br /> it a rm <br /> * <br /> r <br /> \ rgnature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> i <br /> i <br />