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BACKFILL EXCAVATION CERTIFICATE <br />LocationProject <br />f •... <br />Owner 5)9M 4 1n6R1 142i <br />r37? <br />Contractor WgW7-lo /9 Phone No. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or -- 'Fe; tot- 6 E x Cu vu�®w <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 y\ r LA.-, C Keo- vcrh o v� <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 Mass 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 Buiding Code <br />Appendix Chapter 70. <br />* <br />C: C, <br />Name t) . <br />* Shall be the responsible managing employee on the license or authorized agent. <br />� - � �/� cs Zqc% //7 sir 7/1"/1 <br />U <br />