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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location `bola Lc ct C a Ll o <br /> Owner " , t_�v:��\ Phone No. .2p 9 - 31-31 •72/Q" <br /> Contractor cTon.)N LL cL. Phone No. .209- B63-C)"?58' License No. (aSl Sd t <br /> / INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> s2. ubmission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> ubmission 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 /> VIB. 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 da s of pproject 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 /> * arAee tin JlP <br /> nt) � <br /> * rcS <br /> t ( tint) <br /> nature <br /> * Shall be the responsible managing employee on the license::thorized agent. <br />