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<br /> <br /> <br />10 of 10 <br /> <br />Environmental Health Department <br />BACKFILL EXCAVATION CERTIFICATE Project Location:__________________________________________________________ Owner____________________________________ Phone No:___________________ <br />Contractor:________________________________ Phone No:____________________ <br /> <br />License No:____________________ <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE __ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or ___ 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was placed in the excavation in 12" lifts: ___A. Pea gravel--smooth, rounded material not more than one-half (1/2) inch in diameter ___B. Crushed rock--self-compacting material not more than three-quarters (3/4) inch in cross sectional measurement. (Use of crushed rock will not be permitted for backfill if contact will be made between the backfill material and tanks/pipes made of poly resin glass or similar materials.) DECLARATION I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or submission of verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code Appendix Chapter 70. *Name . <br />(Print) Title . <br />(Print) Signature . <br /> *Shall be the responsible managing employee on the license or authorized agent.