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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 8 d 1r) Cru fa;/n^�� 41A�l <br /> Owner '){ct{-e CA l i� nicer �t Phone No. 3�.3— ci$-7� <br /> Contractor xtrd L .�Ytreder + Phone No. �I(p ga I/Cq License No._ (D�(psC]U <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> �Q 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials <br /> was placed in the excavation in 12" lifts: <br /> DC A. Pea gravel--smooth, rounded material not more than one-half(12) 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 <br /> the 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 roject completion,or submission <br /> of 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 <br /> Code Appendix Chapter 70. <br /> Name ( rint) <br /> l' e (print) <br /> signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />