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_ACKFILL EXCAVATION CERTIFICATE <br /> Project Location_ 5- p�� 67 IO�����/' L <br /> Owner l pi f���' Phone No. 204 3, Z <br /> Contractor 0 O/ Phone No. Td% JG/f`{�� 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. Subn'-sion of verification, u., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12 lifts: <br /> XB <br /> A. Pea gravel--smooth, rounded material not more than one-half(1/2) inch in diameter <br /> . Crushed rock--self-compacting material no[ 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 olon 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. ll <br /> * <br /> y Name not <br /> n e rent �4 <br /> * <br /> — Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />