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~~ ~� <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: ' <br /> Phone N0 <br /> ' Phone No: <br /> Contractor <br /> License No: <br /> INDICATE METHOD OFBACKFILL QUALITY ASSURANCE <br /> 1� Submission of Soil Engineer's Compaction Report within 30 days of project <br /> --- completion, or <br /> ' <br /> �� Submission of verification, e.g. load ticket,. within 30 days of project completion that <br /> �--' one nfthe foUnvxingnn'a `r`|owas placed |nthe excavation in12'' lifts: <br /> - A. Pen gravel--smooth, rounded material not more than one-half(1/2) <br /> ---- inch in diameter <br /> ---B, Crushed rock--self-compacting material not more <br /> than three-quarters <br /> (314) inch incross sectional measurement. (Use ofcrushed rock will <br /> �rmi�edfor backfill ifcontact will bennedabetween the <br /> backfilnot be permitted <br /> and tanks/pipes made ofpoly resin glass orsimilar <br /> rnobsr\a|s.) <br /> DECLARATION <br /> | hereby certifythot o Soil Engineer's Co action Report will be submitted within 30 days <br /> rojectcompletion <br /> submission nfverication that the select material described above <br /> f WilFbe placed at a minimum offive (5\ cubic yards per 1OO� ga\|mn �ank diup\aoenn�nt and <br /> that the en '- will be backfilled` end compacted to insure compliance with the <br /> � excavation vv compactedUnifornnBuUn—CodeAopend|xChopter70. <br /> � <br /> Shall be the responsible managing employee on the license or authorized agent. <br />