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11-06-1997 S = 56'Ar1 FROH,i . P.2 <br />BACKFILL EXCAVATION CERTIFICATE. <br />Project Location 33c -o WEST CANE 4 STo C K_r01J / Cit_— <br />Owner UA MAV --V Me, ( LR-A-TH Phone No. � �a`f� 9 (oZ- - S � 0 � <br />Contractor WA C.Tod 6V CTI /!6&-P-/,1JPhone No��16Z3? 3 ' I f �o License No. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />Submission of ii Engineer's Compaction Report within 30 days of project completion, or <br />J2. <br />Submission o verification, e.g., load ticket, within 30 days of project completion that one of the following Triatcrials was <br />placed in th excavation in 1'2" 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 (314) 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 f ve 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 />kA A-7 <br />ame (Print) <br />NY, a2 <br />* $ball be the responsible managing employee oxt the license or authorized agent. <br />