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BAWILL EXCAVATION CERTIFICATE IS <br />Project Location—i' `� <; lQ O i h \ t� J–T '-�–C U C i l� <br />Owner A_R LCAl� `���� V C 't E_ Phone Nc� <br />Contractor Lz s ; Phone No 12`�� 5 \ -^1 4 License No. �n) X13 <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 />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 ofpproject completion, or submission of <br />verification that the select material 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 />ame rmt <br />* st�_L i N P,\1� C �R <br />Title rm <br />signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />