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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 7 3 Y 3 PL),-.S 7 Zc,,,,-7 e- - <br /> Owner Ar_C115e1- Phone No. Z 6;- 7,5'9 <br /> Contractor Lri I� /A e.,&f Phone No. 7 <br /> -55' License No. -e5 <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.,v 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 <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 glass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of�roject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of Live 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 /> J04 Z_ <br /> ame rint) <br /> I -e--L <br /> at rinLt <br /> )ature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />