Laserfiche WebLink
BACKFILL EXCAVATION CERTIFICATE <br />Project Location ��% �� c� � inn r::e� T c C- 4 -4 <br />Owner (�/iGVkr✓r� 1� ra �-r5 `' Phone No. �.:a3 - � y Z- 460 c' <br />Contractor �� ' 1��yr��i ),-J 6 Phone No. J,?S S "�'� '� JLicense No. ' 713 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />within 30 days of project completion that one of the following materials was <br />2. Submission of verification, e.g., load ticket, <br />placed in the excavation in 12" lifts: <br />JC 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 roject completion, or submission of <br />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 Code <br />Appendix Chapter 70. <br />72 <br />acne <br />L� <br />it t <br />signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />