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/ �/ BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: C / AU//C ✓" 61?Z11i21rJ111 517,� � <br /> Owner:0, r/— J�DIi/l/Oi✓� Phone No: 2e <br /> Contractor:�� �i7li�'/('P� DSL/till• Phone No:& % _32%Afcf/ 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 /> .,KA. Pea gravel—smooth,rounded material not more than one-half(1/2)inch in diameter <br /> B. Crushed rock—self-compacting material not more than three-quarters (3/4) inch in cross sectional <br /> measurement. (Use of crushed rock will 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 materials.) <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 <br /> Zs <br /> (5) cubic yards per 1000 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building.Code <br /> Appendix Chapter 70. <br /> /kF t <br /> • VrtMVAM Mev <br /> itte rmt <br /> ,signature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />