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BACKFILL EXCAVATION CERTIFICATr <br /> Project Location 3,0�7 10 <br /> Owner Ae,4417 elead�l <br /> A Phone No. <br /> Contractor E, &1/1&3 &JS( / Phone No. ��� rQ.icense No. 73'040 <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.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 /> _ 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 ofpprcject 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 /> * L7/1�/Bi✓ �///yrG��LCS"W <br /> Name(Pnm) <br /> Tit a(print) - <br /> � o tgnature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> 1 <br /> j <br /> i <br /> 1 <br />