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BACKFILL EXCAVATION CERTIFICATE <br />l ( � uJb-� LD c1 15 E � �' it -,01 <br />Project Location t�S IAC phone No. <br />Owner <br />MOW- 5 °P License No. dol9- Z3�' <br />Contractor UW�'�� 61' <br />Phone No. (�f 16� ?3" 1168 <br />INDICATE METHOD OF BACKFILL- QUALITY ASSURANCE <br />eCL Completion, Or <br />1. Submission of Soil Engineer's Compaction Report within 30 days of proj materials was <br />—/ load ticket, within 30 days of project completion that one of the following <br />✓ 2. Submission of verification, e.g., <br />placed in the excavation in 12" lifts:inch in diameter <br />V/ A. Pea ;ravel <br />_--smooth, rounded material not more than one-half (1/2) inch in cross sectional <br />uarters (3/4) the <br />B. Crushed rock -self -compacting mwill aterial not more than or ba Q <br />e °fpoly <br />of resin glass or similar materials.) <br />k not permitted for bac <br />measurement. (Use of crushed rockfill if contact will be made between <br />backfill material and mnks/pipes mad P <br />DECLARATION <br />d at a minimum of flue (5) cubic yards per 1000 gallontank <br />Engineer's Compaction Report will be submitted within 30 da s of project completion, Or B ildtng °II of <br />ode <br />1 hereby certify that a Soil <br />d that the entire excavation will be backfilled and compacted to insure compliance with the <br />verification that the select material described above will be place <br />displacement an <br />Appendix Chapter 70. <br />* M1KE SEE 14.t.A <br />ame ( rtnt <br />* A Dz, N1ib✓f4------------ <br />pez- <br />t e ( t) <br />I� <br />ignature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />