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`iCKFILL EXCAVATION CERTIFICATE <br /> Project Location <br /> ,_` ��. '� � 1 ¢L <br /> tL <br /> Owner � G- Phone No.� <br /> Contractor {_ .I ldL 2 SC 1� � L� 4�h i'�phone No.�'M q '1 5 `�D ,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.F , 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 <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 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 /> ame nn[ <br /> t)— 2 <br /> itle rm <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />