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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: 2 5 Z 1 W 100400 0 J'ii" .f r X7-06 <br /> Owner36k Oise kDIM-10)(906 p) Phone No: i"' 9?-[ " Z <br /> FFo62 <br /> Contractor: M P r l Ste" Q"`v""o\1 Phone No: 66 0 <br /> License No: <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1.Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2.Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> 4101 G <br /> oneofthefollowin <br /> A. Pea gravel--smooth, rounded material not more than one-half(1/2) <br /> inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quarters <br /> (3/4) inch in cross sectional measurement. (Use of crushed rock will <br /> not tie permitted for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin glass or similar <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> of project completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 7((0. <br /> *Name got Jl�'�lf4ti <br /> nn <br /> Title <br /> -'— rrnt <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br />