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�%w/.CKFILL EXCAVATION / <br /> ''TIION CERTIFICATE � <br /> Project Location C4'- W6::�4 i csLr-ocp-� <br /> Owner fA4 - gAt P L. VANA"ZoIR Phone No. <br /> Contracto%� 0� hone No. 3 License No.cZ <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> I Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> ✓ 2. Submission of verification, e.v load ticket, within 30 days of project completion that one of the following materials was <br /> placed inthe/ez�a�ation in 12 lifts: <br /> A. Pea gravel-smooch, rounded material not more than one-half(1/2) inch in diameter <br /> B. Crushed rock-self-compacting material not more than three-quar[ers (314) 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 vards 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 /> N=)tm[ <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />