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• <br />• <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location 27 ? -5 C_0Un+r- L-1OLF 151YA- StDe-kiorl <br />Owner So,s��i d Gorpo�ntion Phone No. (�il�) `to31 7711 <br />Contractor '11c-lneibs C_Oora�fo Phone No. 65� z 595- 455 -)—License No. 553!) 33 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within. 30 days of project completion, or <br />y% 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of tate following materials was <br />placed in the excavation in 12" lifts: <br />A. Pea gravel—smooth, rounded material not more than one-half (112) inch in diameter <br />B_ Crushed rock—self-compacting material not more than three-quarters (314) inch in cross sectional <br />measurement. (Use of crushed rock will not be permitted for backfill if contact will be trade 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 of roject 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. amu.-rr►Iand Cu;lechCn <br />ame t <br />'i'It'fe (Frtnt` j , <br />t <br />* Shall be the responsible managing employee on the license or authorized agent. <br />