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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location � �a �G'1— -AVG . sG4 wf,4 C <br /> Owner_ C q <br /> Phone No. <br /> Contractor Phone No. <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 /> 2. Submission of verification, e.� , load ticket, within 30 days of project completion that one of the following m <br /> placed in the excavation in 12' lifts: o materials was <br /> _ A. Pea gravel--smooth, rounded material not more than one-half(1/2)inch in diameter <br /> Crushed rock--self-compacting material not more than three-quarters (3/4) inch in cross sectional <br /> measurement. (Use of crushed rock will 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 materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of roject completion, or Submission of <br /> verification that the select material described above will be placed at a minimum of five 5p) <br /> displacement and that the entire excavation will be backfilled and compacted to insure compel ante with cubic the.Uniform But din n tank <br /> Appendix Chapter 70. o Code <br /> Name (Print) <br /> tt a rmt <br /> tgna re <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> I <br />