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BACXYIL- EXCAVATION CERTIFKATE <br />-oject Location IQ(0 W. L-,o J /�r IM z�A CA <br /> unci Qy I S T.oP VK�s � l 1J C Phone <br /> onactor wAt,To� �Ncsrn��i�l&� 1 <br /> 1JG ne Phoz-401I(0 313-� 1�8 License No. (el <br /> crZ 3 8 <br /> INDICATE M.- MOD OF BACIGML QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion. or <br /> 2. Submission of verificarion. 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 /> vl�. Pea gravel—smooth, rounded material not more than one-half(112) inch in diameter <br /> B. Crushed rock—self-campactii 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 mate.-ials.) <br /> DECLARATION <br /> hereby certify that a Soil Engineer's Companion Report will be submitted within 30day sof project completion. or sugallon bmission of <br /> trificatioa that the select mAerial described b°backf lied ivill be and comoact�omsum comoum of tivelianc-with bic th Uariis pe-. <br /> f Uniform Buillding Cod <br /> :salacemcm and that the entire excavadoa will <br /> poeadix <br /> Chaoter. 70. <br /> ame l t) <br /> Q N7 <br /> igna ure <br /> ie <br /> Shall be the responsible managing e=Ployee an the license or aitthotixed agent. <br /> T 2c vi�d� i*Of::' %4/7A cs 6ac4 %n/ <br /> U <br />