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BACKFILL EXCAVATION CERTIFICATE <br /> 40 Protect Location �K V n'�Q� , S toy k rte^ <br /> Owner L)ALk1r5f Gor fafio n Phone No Zoq g4(t_-¢36 4( <br /> ' Contractor Env r mon nur t-C"(f..411 Phone No b67-7300 License No AJ4A'3 ;Z <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> I 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" lilts <br /> A Pea gravel--smooth,rounded material not more than one-half(1/2) inch in diameter <br /> B Crushed rock--self-compactmp, 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 the <br /> 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 /> 1 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 /> * <br /> Title(Print) <br /> Signature <br /> ' * Shall be the responsible managing employee on the license or authonzed agent <br />