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I� N J O A Q i I jI N Environmental Health Department <br />-f- COUNT Y---- <br />. <br />BACKFILL EXCAVATION CERTIFICATE <br />>ject Location: 20500 Holly Drive, Tracy CA 95304 <br />Owner Phelan Developement <br />Contractor: Tracy Grading And Paving, Inc. <br />License No: 990699 <br />I <br />Phone No: <br />Phone No: 209-839-6590 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />X 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 />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 />DECLARATION <br />I 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 />*Name Robert Rocha <br />n nt <br />Title President <br />rint <br />Signatu <br />*Shall be the responsible managing employee on the license or authorized agent. <br />