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I <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location 2-1:)z 2 <br />Phone No. <br />Owner _P) License <br />Contractor. VA L F_ phone <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 <br />"v( 2_ submission of verification, e.F;,, load ticket, <br />was placed in the excavation in 17 lifts: <br />,X A. Pea gravel—smooth, rounded material not more than one-half (112) inch in diameter <br />�rs (3/4) inch in cross sectional <br />Crushed rock—self-compacting material not more than three -quarte <br />B. 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 />ubmitted within 30 days (Project <br />com letion. or submission <br />I herebv certify that a Soil Engineer's Compaction Report will be s minimum of five (5) cubic yards per 1000 gallon tank <br />of ver"cation . that the select material described above will be placed at a min Uniform in the entire excavation will be backfilled and compacted to insure compliance with the Unifo Building <br />displacement and that <br />Code Appendix Chapter 70. <br />M <br />• Shall be the responsible managing employee on the license or authorized agent. <br />