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;925 551 7888 # 33/ 34 <br /> 5-27-04; 8:43AM; <br /> 03/05/2004 13:59 2094683433 FIFTH FLOOR PAGE 15 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location G.Qt_&rY AVP. t.SCAL0t 4 <br /> owner ZL <br /> Phone No. 0Z3 <br /> Contractors Phone No. License No. <br /> INDICATE METHOD GF BACKFILL QUALITY ASSURANCE <br /> Z_ 1. Submission,of Soil tr4ineer`s Compaction Report within 30 days of project completion,or <br /> V 2. Submission of verification,e.glifts:., load ticket, within 30 days of <br /> placed inthe excavation in 12 prajeet completion that one of the following materialss was <br /> � <br /> Y A. Pea gravel--smooth, rounded material not Weare than one-half(I/2)inch in diameter <br /> . Crushed rock•set€-compactt�t Material not more than three,gcarters (3/4' inch in cross sectional <br /> megAttement. (Use of chished rock will mot be' ermitted for backfill if contact will ba made belWeen the <br /> backfill material and tanks/plpca made of poly resin gWs or similar inateriatis_) <br /> DECLARAn®N <br /> e <br /> I hereby cmdfy that a Soil Engineer's Compaction Report will be submitted within 30 days of rojeCt completion, or submission of <br /> verification that the sept material described above will be placed at a um of fiive ($ cubic yards ties I r s On tante <br /> displacement send that rite entire excavation w11 be backfMcd and to insure compliance with the ZJtiiform Hut ding Cade <br /> Appendix Chapter 70. <br /> Name rant <br /> ine <br /> a c <br /> i <br /> " Shall be the responsible managing employee on the license or authorized agent, <br /> - <br /> M <br />