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BACKFILL EXCAVATION CERTIFICATE <br />Project Location �AN <br />K,, 0'f e. t Phone N4 -< D0 ) Y65_ -2fo j b <br />Ar T 1 � -- );Q KAO 1t'rkone No. (1w) ^� T° - 7"16 License No.- 4-&k 196, <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 (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 da s 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 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 />Name (Print), <br />Tit e <br />* <br />Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />None N" es5 eub t (� WS <br />KO -VL WA$ d+2`\VCy{ IN ir)N; <br />3/a Fr -J -J, CmAs�QA t,c,k , <br />I q .AY TONS. <br />