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Project Location <br />Owner <br />BACKFILL EXCAVATION CERTIFICATE <br />DDRW— Sharoe Facility. 700 E. Roth Rd., Lathrop, CA 95330 <br />Same as above <br />Phone No. (209)982-2427 <br />Contractor JIM THORPE OIL, INC. Phone No. (209)368-6175 License No.495699 <br />INDICATE MEiTIOD 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 <br />was placed in the excavation to 12lifts: <br />A. Pea gravel --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 (3/4) 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 />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days ofroject completion, or submission <br />of 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 <br />Code Appendix Chapter 70. <br />JIM THORPE OIL,INC. <br />ame(Print) <br />CONTRACTOR <br />lip, <br />, 1% WON <br />* Shall be the responsible managing employee on the license or authorized agent. <br />