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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location rl <br /> Owner—D4.1 ,-.,.}-d.6Pe t E e le um Phone No. 209-943-9011 <br /> _ <br /> Contractor �� n ,�., __ _Phone No. License No.,283424 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> XX I. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> T 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 /> A. Pea gavel—smooth, rounded material not more than one-half(1/2) 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 /> 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 /> displacement and that the entire excavation will be backfilled and coinpaged to insure compliance with the Uniform Building Code <br /> Appendix Chapter 74. <br /> Name t) <br /> i <br /> .a. L. <br /> t e tin / <br /> * �' <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />