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*ACKFILL EXCAVATION CERTIFICATE 10 <br />ProjectLocation WoO 1—ouotr Sesci-amr.ok 0 <br />Owner 01"e <br />Lks"p, Phone No. <br />Phone No. t)cj� License No. <br />Contractor kjt�g (ZV\_s*-____ <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.�., 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 <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 of project 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 />Name not <br />Pty s% Age, <br />e Fr1-4 Tt <br />ignJature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />