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i+ <br /> + LS(7CLKFILL EXCAVATION CERTIFICATE U <br /> Project Location (Z'fi pt , <br /> Owner i ��i Z CAU itrJ14 6*1-4 4). ,LPhone No. CZ� `1+��_ ,3 <br /> Contractor SEMCO Phone No.(209) 524-9653 License No. 449864- <br /> i <br /> INIDICATE 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 /> laced in the excavation ' <br /> p o to 12 lifts: <br /> l K A. Pea gravel--smooth, rounded material not more than one half(112) inch in diameter <br /> 'k B. Crusted rock—self-compacting material not more than three-quarters (314) inch in cross sectional <br /> measurement. (Use of crushed rock will not be pertnitied for backfill if contact will be made between <br /> the backfill material and tanks/pipes ;Wade of poly resin glass or similar materials.) <br /> I ; <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within'30 days of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000 gallon tank <br /> I displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br /> Appendix Chapter 70. <br /> * J( <br /> Name rint <br /> It e t <br /> Signature <br /> * Shall be the responsible managing employee on the"license or authorized agent. <br /> l <br /> ,L <br /> F I� <br /> f I <br /> k <br />