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• purj V <br />UG 2 � 2� <br />SAN,d A R U I N Environ Ith Department <br />--COUNTY— t4vIR0F -TAL. <br />CEPP.RTF_N,T <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location: <br />5�(oZ% Davi her <br />DPt UZ. &4cl4-A6A <br />; C q L?5'7 <br />Owner 7-&kotM <br />v ZO�o�vZ- <br />Phone <br />No: <br />Contractor: /,.L s>cr04,cs Phone No: s",s-q, Los- n?b <br />License No: 771067 <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 <br />that one of the following materials was placed in the excavation in 12' lifts: <br />A. Pea oravel--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- <br />quarters (3/4) inch in cross sectional measurement. (Use of <br />crushed rock will not be permitted for backfill if contact will be made <br />between the backfill material and tanks/pipes made of poly resin <br />glass or similar materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 <br />days of project completion, or submission of verification that the select material <br />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 <br />compliance with the Uniform Building Code Appendix Chapter 70. <br />*Name Jose Rios <br />(Print) <br />Title Manager, Environmental Services <br />r <br />Signature <br />*Shall be the responsible managing employee on the license or authorized agent. <br />10 of 10 <br />