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• <br />Project Location <br />Owner <br />Contractor <br />SCKFILL EXCAVATION CERTIFICATE • <br />C;- <br />Phone No. 6:1 4VZ D3o�- <br />License No. 4/0 BoZL� <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.g.; load ticket, within 30 days of project completion that one of the following materials was <br />placed in the excavation in 12" lifts: <br />_�4,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 <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 project completion, or submission of <br />verification that the select matenal described above will be placed at a minimum of five (5) 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 />Nitne (Print) <br />..—� Print) <br />nature <br />- <br />* Shall be the responsible managing employee on the license or authorized agent. <br />