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BACKFILL EXCAVATION CERTIFICAT <br /> Project Location G <br /> Owner Phone No. 9® 1-/ <br /> Contractor 1 U.eh' fM1neeftAAPhone No. Q-0 by-2014 License No. 81161-L /H <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 da s 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 /> * �, I� r✓l n 'I <br /> Name(Print) <br /> * r <br /> it a rort <br /> +l <br /> 4 <br /> LAWIgliaiture <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> I <br /> I <br /> + <br /> i <br />