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C� <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location rP ,;Z 8 S <br />U , F 2 c <br />rn w+ 54, <br />%S o? ® s <br />Owner Quilt 6 a /10 <br />MaRb7S <br />zlyc ® <br />Phone No. S'/8„) !�S 3' -9-T,00 <br />Contractor Wo 14 , P--hG <br />1 tv rte rias <br />Phone No. ( <br />%/6),3ia ®/d fd License No. 912,2343 <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-hoif meter <br />B. Crushed rock -self -compacting material n. ) inch in cross sectional <br />measurement. (Use of crushed rock will no �(, t will be made between the <br />backfill material and tanks/pipes made of po <br />DECLARATI <br />I hereby certify that a Soil Engineer's Compaction Report will be subm.,�c�� uompletion, or submission of <br />verification that the select material described above will be placed at a uummum of five (5cubic 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 />* m i k E I-. r-- a <br />arae rant <br />* Shall be the responsible managing employee on the license or authorized agent. <br />