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Environmental Health Depart <br /> SAN Q A Q U Nment <br /> COU NTY - <br /> I <br /> I <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: 3 d /9G/irlc!� 5r'Zo 7- <br /> owner C ����� iZ 4//�S/� Phone No:dO <br /> Contractor: ..?/01 l Al e, Phone No: ,?,O <br /> License No: 5 9 9 <br /> EaD <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE JUL 2 9 2070 <br /> 1. Submission of Soil Engineer's Compaction Report within 30 day8yN SAL HEALTH <br /> completion, or i isERviccs <br /> i <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion <br /> that one of the following materials was placed in the excavation in 12 lifts: <br /> oy,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- <br /> quarters (3/4) inch in cross sectional measurement. (Use of <br /> crushed rock will not be permitted for backfill if contact will be made <br /> between the backfill material and tanks/pipes made of poly resin <br /> glass or similar materials.) <br /> i <br /> DECLARATION <br /> fi <br /> 3 <br /> 1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 <br /> days of project completion, or submission of verification that the select material <br /> 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 <br /> compliance with the Uniform Building Code Appendix Chapter 70. <br /> 3 <br /> *Name <br /> nn <br /> Title <br /> nn <br /> QL <br /> i <br /> Signature <br /> { <br /> I <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> r <br /> 0 <br /> 0 1= /p <br />