Laserfiche WebLink
BACKFILL EXCAVATION CERTIFICA* <br /> Project Location <br /> Owner. Phone N <br /> Contracto Phone N<55 <br /> 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 /> V 2. Submission of verification e.F., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12 lifts: <br /> v1 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- in al <br /> backfill <br /> (3/4) inch cross section <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 10 da <br /> Is of1roject completion, or submission of <br /> r <br /> verification that the select material described above will be placed at a minimum of We 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 /> Name (Print) <br /> I-it e (Frinq <br /> V,, <br /> iloature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />