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BACKFILL EXCAVATION CERTIFICA" <br /> rojtSFt Location /Z y �7 ._/ + Q �� S <br /> ? Q <br /> Owner_foole/ W� }. ` <br /> S Phone No. s3• 9_�Q��+ 7�d <br /> )J <br /> Contractor%Vo ,,6j& */,.Li7C.Phone Ngjft •349 o•10��SLicense No.yss` 7 7 <br /> W �— <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 of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000gallon tank <br /> th <br /> displacement and that e entire excavation will be backfilled and compacted to insure compliance with the inform Building Code <br /> Appendix Chapter 70. ' �U s RPL D '� l <br /> ame curt) <br /> �c G - <br /> ttPrint) <br /> [gnature <br /> • Shall be the responsible managing employee on the license or authorized agent. <br />