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Project Location <br />Owner <br />Contractor <br />&CKFILL EXCAVATION CERTIFICATE 0 <br />Phone <br />Phone No <br />License No. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br />placed in the excavation in 12" lifts: <br />_ A. Pea gravel --smooth, rounded material not more than one-half (112) inch in diameter <br />_ B. Crushed rock—self-compacting material not more than three-quarters (3/4) inch in cross sectional <br />Elie backfillnmaterial and tanks/pipes [Wade of poly Use of crushed rock will not be resin glass or simd for ilar if <br />well be made between <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of pproject completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (5) cubic yards per m B gallon tank <br />displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Cade <br />Appendix Chapter 70. <br />t ame ( nnq <br />u e ( rtn[) <br />tgnamre <br />Shall be the responsible managing employee on the license or authorized agent. <br />