Laserfiche WebLink
`SSACKFILL EXCAVATION CERTIFICATE <br />Project Location: P&ASKY ptv�tr <br />Owner: £ M" 1 a" S K Y Phone No: <br />Contractor: Y'r T1%Ori Oi I Phone No: 4fDZ- c1SbI License No: �/ySb9Q <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />1( 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 />X 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 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 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 he backfilled and compacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 70. <br />w <br />Name not <br />' Shall be the responsible managing employee on the license or authorized agent. <br />EH 23 046 (Revised 10/16/03) Page 11 <br />