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RECEIVED <br />BACKFILL EXCAVATION CERTIFICATE NOV 2 2 2016 <br />Project Location: 8476 E. Kettleman Lane Lodi, CA 95240 ENVIRONMENTAL HEALTH <br />9EPARTIVIENT <br />Owner Rodney cede and Linda D. Gaede Phone No: (209) 639-7012 <br />Contractor: Terry_D_ Hamilton Phone No: 209 404-7700 <br />• is GA R7. 1 WE. <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 />x 2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br />one of the following materials was placed in the excavation in 12" lifts: <br />X A. Pea gravel --smooth, rounded material not more than one-half (112) <br />inch in diameter <br />B. Crushed rock--self-compacting material not more than three-quarters <br />(314) inch in cross sectional measurement. (Use of crushed rock will <br />not be permitted for backfill if contact will be made between the <br />backfill material and tanks/pipes made of poly resin glass or similar <br />materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br />of project completion, or submission of verification that the select material described above <br />will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br />that the entire excavation will be backfilled and compacted to insure compliance with the <br />Uniform Building Code Appendix Chapter 70. <br />*Name Terry D. Hamilton <br />rin <br />Title Contractor <br />nn <br />Signature <br />*Shall be the responsible managing employee on the license or authorized agent. <br />