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F(1EGt:JV Luo <br /> WS 2 1 A <br /> EnXLJ�pllth Department <br /> SAW-JOAQUIN vironm TAL <br /> ­COUNTY— J1 _v4 <br /> _t4\ Ft01.4MF <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: DoAff- s4ec'!6pn iq <br /> Owner <br /> 'CU c,* Phone No: <br /> Contractor: Se-ko'cle-r. Phone No: s7,,;,q '-vLir n?6 <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 lifts: <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- <br /> quarters (314) 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 "laced 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 /> (P rA <br /> A IyA <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> 10 of 10 <br />