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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 7(; ) -2n a-b t-P 7 4 go-P (A L t P;�R�,I to <br /> Owner i�r=crit �,�TrZ t �T',at,s �AN JQALwu _-S!4AZEI Srrs- Phone No. 7�) ZO7y <br /> Contractor iq L JntG Phone Nohr,() �i�{e--7�1�!�� License No. (g7-775-4 <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 mare:;als was <br /> placed in the excavation in 12" lifts: <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 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 ofroject completion, or submission of <br /> verification that the select material dcscriticd 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 Code <br /> Appendix Chapter 70. <br /> Name ( Erin—) —� <br /> T <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />