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BACKFILL EXCAVATION CERTIFICATE <br /> _7 7'11/10f'! i. P�_ <br /> ?rojCCE Location j'�7(_% <br /> Phone NO. Y <br /> Z-17—i <br /> License No. <br /> Phone No.7C"r­ <br /> Con(ractor'-.,-,J-_4S:j. --,L; <br /> INDICATE METHOD OF BACKFILL OUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 2. Submission of verification, e.g., loud ticket, within 30 days of project completion that one of the following materials <br /> was placed in the excavation in 12' lifts: <br /> A. Pea gravel--smooth, rounded material not more than one-half(IP-) 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 <br /> the 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 r0. t completion,or submission <br /> �njec comp e <br /> of <br /> t verification that the select material described above will be placed at a minimum of five ( cubic yards per 1000 gallon tank <br /> displacement <br /> lacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> N (Print) <br /> Igna e <br /> Shall be the responsible managing employee on the license or authorized agent. <br /> f J <br /> a, <br /> "4 <br /> ­_Cy <br /> �� ru- <br /> 15. <br /> 4' <br />