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9255517899 ' Line 1 r, 9:38 p.m. 11-04-2010 7/13 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: SS rG •L.ow%S6 oc*•v 6 . <br /> Owner WW wG -r C4=b•.4r- PReOucx%& LA-C' Phone No: —7114. CO-70. 3WG05 <br /> Contractor: Gt5•rTLFP Q+a�� , i P-AC Phone No:' C)=Tv• 'S�•"7�5� <br /> License No: -7 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1.Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2.Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> one of,the following materials was placed in the excavation in 12" lifts: <br /> VA. Pea gravel—smooth, rounded material not more than one-half(1/2) <br /> inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quarters <br /> (3/4)inch in cross sectional measurement. (Use of crushed rock will <br /> 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 <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> ofproject completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> j6 iam ��-Iola) � <br /> *Name (Print) <br /> o n1Zf- �Ac <br /> Title nn <br /> r <br /> all be esponsible managing employee on the license or authorized agent. <br />