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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location �O� 1 } =� �.1 DV�` I \dZ `TW C4 ' — <br /> OnePhone No _ _9` )0 }9 _ -- <br /> Contractor Phone No ���1 X ], ] License No rJ ts� <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1 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" lifts <br /> \!goA 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 <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials } <br /> DECLARATION <br /> 1 hereby certify that a Soil Engineers Compaction Report will be submitted within 30 da of project completion, or submission of <br /> ys P J <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 Tint <br /> Fitle (Print) <br /> c <br /> i nature <br /> Shall be the responsible managing employee on the license or authorized agent <br />