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P. 12 <br /> BA FILL EXCAVATION CERTIFICATE <br /> Project Location—_0W V/ G�Ow /2o.4N �® <br /> _ <br /> Owncr JFQ r Ji L 0 J C_ f C . <br /> Phone No. 7ZS—' 3 = . 00o <br /> Contractor �� �� KEG Phone No.j/0—611/- _ License No. b 9pG� <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 foll�winJ <br /> placed in the excavation in 12" lifts: materials was <br /> A. Pca �ravcl•-smooth, rounded material not more than one-half(1/2) inch in diameter <br /> B. Crushed rock--self-compacting material 110E snore than three-quarters (3/4) inch in cross sectional <br /> measurement. (Use of crashed rock will not be permitted for backiilI if contact will be made between <br /> the baekfilI 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 of project 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 /> * _P <br /> AIJL A s� <br /> Name (print)p <br /> I Pr <br /> natu ' <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />