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SAN ) O A Q U I N Environmental Health Department <br /> C 0 U N T Y <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location : 4627 DaVinci Drive , Stockton , CA 95207 <br /> Owner 7- Eleven #20632 Phone No : <br /> Contractor : L . C . Services Phone No : 559 -444- 1730 <br /> License No : 779267 <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 <br /> that one of the following materials was placed in the excavation in 12 ' lifts : <br /> x A . Pea gravelm-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 /> DECLARATION <br /> 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 bbackfilled and compacted to insure <br /> compliance with the Uniform Building Code Appendix ,Chapter 70 . <br /> * Name C ' O \ `� \l \C`. <br /> �a nn <br /> Title <br /> Signature <br /> \\ ).6. <br /> l <br /> * Shall be the responsible managing employee on the license or authorized agent . <br /> 10 of 10 <br />