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BACKFILL EXCAVATION CERTIFICATE <br /> � L®viSE AVFi <br /> project Location l ( k' WETS Phone No. �c,ol 65�- <br /> Owner 09 1 �� -1 I(PS License No. (o!+ <br /> IM4Z3$ <br /> Contractor L't7� <br /> 6`�f nl�G' Phone yo.�Q l6� • <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> s of project completion,,or <br /> s Compaction Rep materials was <br /> V/1- Submission of Soil Engineer' ��30 ys of project completion that one of the following <br /> ✓ 2. Submission of vetificaatic ,e.g., load ticket, <br /> placed in the excavation in 12" ltfcs: m diameter <br /> v A. Pea gravel—smooth, rounded material not more than one-half(1�� (3 <br /> /4) inch in cross sectional <br /> B. Crushed rock—self-compacting material not more than or ba q <br /> ent. (Use of crushed rock will not be risin glass o similazBmateT1� ) will be made between the <br /> measurem <br /> backfill material and tanks/Pipes made of poly <br /> DECLARATION <br /> y ect completion.or submission of <br /> cubic yards per 1000 gallon tank <br /> that a Soil Engineer's Compaction Report will be submitted within 30 tfive (5) c Code <br /> I hereby certify laced at a mini3lum of Bance with the Uniform Building <br /> verification that the select material described above ` be p acted to insure <br /> displacement and that <br /> the entire excavation will be backfilled and comp <br /> Appendix <br /> * M 1 I1-E LEE- 14,t,� <br /> 1 ame ( rint? <br /> L <br /> i e l t) <br /> �l <br /> r-G- <br /> ignature <br /> * Shall be the responsible managing employee on the license or authorized agent- <br />