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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location elq 4(m4V S f.0 Ovn <br /> Owner U)n e r5f Cor oto Co / Phone No ,207 —`74f j -Q-36 If <br /> ' ContractorEnv r Irti�n a ne�ri �Gon`Idch<k, Phone No Mfr X61-Z360 License No A)4.4 2 'Z J3;2_6 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1 Subrrussion of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> ' 2 Subtussion 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 (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 glass or similar materials) <br /> 1 <br /> DECLARATION <br /> rI 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 Print <br /> 1 it a rent) <br /> Signature <br /> ' * Shall be the responsible managing employee on the license or authonzed agent <br /> 1 <br />