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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: .�,6��' r—FDA12.A 1/i <br /> 1 ' <br /> Owner:_(_V&Z& <br /> oce,Ls. is i Phone No: <br /> Contractor: IVOR.-(?A L ��jV1�'EJj�'T(� PhoneNoj� )666-1112,C) License No: d <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 pemtitted 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 roject 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 not <br /> * �+ S 1 <br /> e not <br /> tgnature <br /> * Shall be the responsible managing employee on the licens?auorized agent. <br /> EH 23 046 (Revised 3/15/02) Page I 1 <br />