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Project Location <br />Owner <br />Contractor <br />BACKFILL EXCAVATION CERTIFICATE <br />Phone No. <br />Phone No. <br />License No. <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 (112) inch in diameter <br />B. Crushed rock--self-compacting material not more than three-quarters (3l4) 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 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 />* <br />Name(Print) <br />* <br />Title (Print) <br />Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />