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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: 32-0 (0 �'`� i. V,_'ZVCV+ <br /> Owner (� T Phone No: Zoe, ASCD -3U39 <br /> Contractor: V n r��e`��. ,�,; T,.. : Phone No:_S!>O— LJ 7 k (v i's <br /> License No: �'(,1-z--3 C ;4— <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> `/1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> one of the following materials was placed in the excavation in 12" lifts: <br /> _A. Pea gravel--smooth, rounded material not more than one-half (1/2) <br /> inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quarters <br /> (314)) inch in cross sectional measurement. (Use of crushed rock will <br /> 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 <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> of <br /> wiproject completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5 cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be bac filled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> wa _C`goyc- ti a Lel. <br /> ame <br /> • we V <br /> itle (Print) <br /> to <br /> igna ure <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />