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1 � , <br /> D'9 BACKFILL EXCAVATION CERTIFICATE ,fi <br /> ' Project Location O1 � D �` <br /> Owner— U0 I Q UIS rT� PrksC \Fl L Phone No a0 9 1 _ <br /> Contractors � �, _ _ Phone No License No - <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 to 12" lifts <br /> ( \CA Pea gravel--smooth, rounded material not more than one-half(112) inch in diameter <br /> } :L- B Crushed rock--self-compacting material not more than three-quarters (314) inch to 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 /> ! hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of pproject completion, or submission or <br /> verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000 gallon tanl <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 /> * U v <br /> Name (Print) <br /> ' it a (Print) <br /> t <br /> onature <br /> Shall be the responsible managing employee on the license or authorized agent <br /> 1 <br /> 1 <br /> 1 <br /> 1 " <br />