Laserfiche WebLink
BACKFILL EXCAVATION CERTIFICATE <br />t <br />% <br />Owner: U.S. Phone No:V5- <br />Contractor:ijJ-1JJ,C&),1opA&k1 <br />r <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 <br />was placed in the excavation in 12" lifts - <br />tA. 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 (3/4) inch in cross sectional <br />measurement. (Use of crushed rock will not be permitted for backfill if contact will be made <br />between the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br />r � • <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or <br />submission of verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000 <br />gallon tank displacement and that the entire excavation will be backfilled and compacted to insure compliance with the <br />Uniform Building Code Appendix Cbapter 70. <br />Name (Print) <br />Title (Print) <br />Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />EH 23 046 (Revised 10/16/03) -g 13 <br />- <br />