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BACKFILL EXCAVATION CERTIFICATE <br /> q. <br /> P . Tbn�2 4i:� -o,94-R- 1 <br /> Ph a of <br /> `- <br /> Cc aeTt <br /> ` Phone No:lkom\— <br /> nse o: <br /> INDICAT THOD OF BAC <br /> 1.Subrnissign of Sod Engineeifs Compaction Reportwithin 30 days of project <br /> completion,or <br /> 2.S n issi of verification, e.g,, load ticket,witNn 30 days of project comp4etion that <br /> one of the folkmdng materials was pladed in the excavation in 12"lift: <br /> A. Pea gra , nded material not more than one-half(112) <br /> inch in diameter <br /> S. Crushed rcacl f material not than re <br /> i in s Anal measurement (Use of crushed fock will <br /> not <br /> perrnitted fbr backfill if contact will be made between the <br /> b ll material and tanks/piper.made of poly resin glass or similar <br /> materials.) <br /> DECLARATION <br /> hereby that a Soil Engineer's Corra n lie `ll su in 30 days <br /> f ject cote A or submission of ri tia the material d � above <br /> `I be placed at a minimum of five (5c ya 1000 gallon tank dis lace nt <br /> and t bac and ed to insure iance with the entire excavation id <br /> nifo Building n Chapter <br /> *Name <br /> T(de <br /> atur� <br /> *Shall be ft responsible managing employee on the license or authorized agent <br />