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i <br /> KFILL EXCAVATION CERTIFICATE 1 <br /> M <br /> Project Location <br /> Phone No. = <br /> Owner f `-t <br /> Contractor ?--' t <br /> INDICATE \4ETHOD OF BACKFILL QUALITY ASSURANCE <br /> —� 1. Submission of Soil Engineer's Compaction Report within;0 days of project completion. or <br /> 2. Submission of verification. load ticket, within 30 days of project completion [hat one of die following materials was <br /> placed in the excavation in 12" lifts: <br /> A <br /> pea gavel--simooch. rounded naterial not more than ane-half(11, inch in diameter <br /> S. C:Z:shed rock--seif-compacting material no[ more [ban :twee-quartets (2;'4) inc;"., M cross sectional <br /> measurement. (Use of Crushed rock will not be permitted for backfil if contact will be made berxeen <br /> the backfill material and [anks/pipes [made of poly resin ;lass or similar materials.) <br /> DECLARATION. <br /> I .e:eby certify hat a Soil Engineer's Compaction Report will be submitted within 30 days of oroject completion, or submission of <br /> ve ification that ue select material described above will be placed at a minimum of ive (�) cubic yards re- 1000 gallon tank <br /> displacement and that the entire excavation will be backliiled and compacted to insure compliance with he Uniform Sunning Cade <br /> Appendix Chapte- 70. ° <br /> tic <br /> ame rant) <br /> u e l_ tint) <br /> tgnanire <br /> Shall be the responsible maiiagin7 employee on the license or authorized agent. <br /> Y, <br />