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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 70?) le� i,&i H gD`P f_A t_t EQRT�tR <br /> 0wner7r'Fyw _ T�e►S 12&,21— SAN JOr� 1u 51F1 P SATE Phone No.�2G�j� <br /> Contractor C A L.- WG Phone No.(797) 144te——T�t�l(� License No. <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 /> ✓ 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 of roped completion, or submission of <br /> verification that the select material described above will be placed at a minimum of 11 � 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 /> Gr u <br /> Name <br /> * <br /> Title(Print) <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />