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Q��N:. ►�. SAN JOAQUIN COUNTY <br />COMMUNITY DEVELOPMENT DEPARTMENT <br />C .-1 <br />1810 E WELTON AVE. STOCKTON. CA 95205 <br />10deDEVELOPMENT SERVICES PHONE (209( 468.3120 <br />PLANNING PHONE: (209( 468.3120 <br />BUILDING PHONE: (209( 468.3123 <br />NEIGHBORHOOD PRESERVATION PHONE (209( 468.3021 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location 3300 West Lane Stockton, CA 95204 <br />Owner West Lane Fuels Phone No. (209)462-8707 <br />Contractor Jim Thorpe Oil, Inc. Phone No.(209)368-6175 License No. 495699 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project <br />completion, or <br />x 2. Submission of verification, e.g. load ticket, within 30 days of project <br />completion that one of the following materials was placed in the excavation in <br />12" lifts: <br />X A. Pea gravel - smooth, rounded material not more than one-half (1/2) <br />inch in diameter. <br />B. Crushed rock - self -compacting material not more than three-quarters <br />(3/4) inch in cross sectional measurement. (Use of crushed rock <br />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 <br />similar materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br />of project completion, or submission of verification that the select material described above <br />will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br />that the entire excavation will be backfilled and compacted to insure compliance with the <br />Uniform Building Code Appendix Chapter 70. <br />* Jim Thorpe Oil. Inc. <br />Name (Print) <br />Contractor <br />T' P <br />* <br />Signature <br />* Shall be the responsible managing employee on the license or authorized <br />agent. <br />6/91-LC/BECERT.DOC <br />