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BACKFILL. EXCAVATION CERTIFICATE <br /> Project Location lZSZ �. sr¢LrJ eo�-1� , sTcl�,�7�i✓ �}UF�QA <br /> Owner 4:72W Tf41;11 14V-7r Phone No a"! '�6 7001 <br /> Contractor ROtl, iV Phone No. ) License No. 7383F 3 g trf`�L <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 /> T A. Pea gravel--smooth, rounded material not more than one-half(112) inch in diameter <br /> ✓ B. Crushed tock--self-compacting material not more than three-quarters (3I4) inch in cross sectional <br /> . measurement. (Use of crushed rock will not be permitted for backfill if coatact 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 Repots 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 (S) 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 /> * /✓1�2Ll�✓�JO'd��iY <br /> Name t <br /> Tide (Prat)I <br /> ignamre <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> 4 <br />