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BACKFILL EXCAVATION CERTIFICATE <br />Project Location 50,5-A*;r— zi` A%t> <br />Owner A/ V,f,/V /Q .0 Phone No.O 7 2�✓r� <br />ContractorHjL elWel;i5; lVOWWi.o hone No. AP? f5770Z/y License No./se"eZL% <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />�1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />V-"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 />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 submined 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 (5p 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 />* Shall be the responsible managing employee on the license or authorized agent. <br />