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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location:_1 ® tc� 76 o ,1-e, tic r v y`' C� • 3� <br /> Owner:--f 1,� C_ -------- Phone No: <br /> ------------------- <br /> Contractor: !u r 1 ��_ C® ______ Phone No:�2�3� <br /> License No: 30 20 IS— <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> one of the following materials was placed in the excavation in 12" lifts: <br /> ___A. Pea gravel--smooth, rounded material not more than one-half (1/2) <br /> inch in diameter <br /> ___B. Crushed rock--self-compacting material not more than three-quarters <br /> (3/4) inch in cross sectional measurement. (Use of crushed rock will <br /> not be permitted for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin glass or similar <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> ofproject completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5 cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> *Name (Print) <br /> ---- ------------------ <br /> (Print) <br /> (_--- <br /> — ------------------------------- <br /> *Title (Print) <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />