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10 0 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location���J���. �{f1�CCg7�� �TUi�L �y�l /, ?S.5 !rx aft Nub A14 �SIC.C,K-*/n, e'4 <br />Owner W�(,T11 �ilU �!���� 01 Phone No..,��1W '%� 6 73 7 <br />Contractor L i [?iQo� Phone No.��[(Q�Llg oy License No. 6711 <br />beDr1W10Z Y6 fr?an4�6 6gt)A#-17&i <br />INDICATE METHOD OF BACKFILL QUALITY ASSURAN JJJJJJJ� gJVTJ <br />_ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or!!1ll1JU L 2 2 1998 IIS`'' JJ'' <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: ENVIRONMENTAL HEALTH <br />_✓ A. Pea gravel—smooth, rounded material not more than one-half (1/2) inch &Ek1l ) RVICES <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 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. �0�� l/11✓1 <br />* �cbbie l�e <br />ame 9 t <br />* Shall be the responsible managing employee on the license or authorized agent. <br />