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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location _ <br /> Owner I A4R- Wr'1 J/tx-LC Clg4eIL Phone No.��— S 8—-7(P14 <br /> 4 <br /> Contractor VC_y LOU 1 Phone No. 8 �2- Sb b License No. :3 )WE; 76 AI—?>R A-2 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> �1. Submission of Soil Engineees 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 <br /> was placed in the excavation in 12" lifts: <br /> _ A. Pea gravel—smooth, rounded material not more than one-half(12) 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 <br /> the 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 <br /> of verification that the select material described above will be placed at a minimum of dve(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 <br /> Code Appendix Chapter 70. <br /> • i2i� M�wul� <br /> game ( not <br /> • plw ec-T MFnn Gtz. <br /> ,l�LtgShall be the responsible managing employee on the license or authorized a <br />