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Project Location <br />Owner <br />Contractor <br />BACKFILL EXCAVATION CERTIFICATE <br />Phone No. <br />Phone No. License No. <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 <br />was 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 ofm of five5 roject completion, or submission <br />of verification that the select material describved aboveill backfilled and compactedlaced at a ni to insure compliancecwath trds he Urer °f�orgmlBuilding <br />displacement and that the entire excavation <br />Code Appendix Chapter 70. <br />* <br />Name(Print) <br />* <br />it a rint) <br />* <br />signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />