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' BACKFILL EXCAVATION CERTIFICATE <br /> Project Location:/ /2 z / �� �-�✓ H. pe-, /fo l <br /> Owner � 6�y A K_ QN4/, CiPhone No: 9�5 / /�4C>a <br /> Contractor:�/ // /L /'+ Phone No: '�( 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 /> �. 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 vill 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 /> DECL tARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or submission of <br /> verification that the select material described above will be z-daced 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 /> * A_ <br /> Name(Print) <br /> * <br /> kTitle(Prmt -- <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />