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• OKFILL EXCAVATION CERTIFICATE <br /> Project Location U T if t I—)Pot <br /> Owner I..,le t I. I r Phone <br /> Contracto Phone N License No. 2- 114 2— <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> ve 2. Submission of verification, e.p., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12 lifts: <br /> v" 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-quaners (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 with'30 da f roject completion, or submission of <br /> in <br /> verification that the select material described above will be placed at a minimum of days <br /> oe (T� cubic yards per 1000gallon 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 /> C_Z>-IT L&10 <br /> Name kPrant) <br /> C'. <br /> Title(Frmp <br /> Tiff a—ture <br /> Shall be the responsible managing employee on the license or authorized agent. <br />