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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location <br /> Owner t. 2 Phone No ,SD1 7£f5-9,700 <br /> Contractor C_ Phone No 207-�S 6-79& - ___ License No <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> I Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 2 Submission of venfication, e g , load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12" lifts <br /> A Pea gravel—smooth, rounded material not more than one-half(112) inch in diameter <br /> B Crushed rock--self-compacting material not more than three-quarters (314) 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 matenal 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 davs of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5) 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 <br /> ns riot <br /> Title nat <br /> signature - — - - <br /> * Shall be the responsible managing employee on the license or authonzed agent <br />