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11 II _ACKFILL EXCAVATION CERTIFICATE <br /> Project Location 3\31t c h 1t Rio 2 C" M1 Odd+•J�Gc K�b cti�\n <br /> Owner U9 S Phone No._2 <br /> Contractor (4MCO t1 2A4 IfKC . Phone No. (a- 3`k Z-71S3� LiceaSe No. S f 3 <br /> INDICATE METHOD of BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion:or <br /> V 2I Submission of verification, e. load ricket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in l2$lifts: <br /> A. pea gravei--smooth, romded material not more than one-half(SM- inch in diameter <br /> B_ Crashed tock—seifcompacting material not more than three-quarters (;/4) inch in cross secrional <br /> measurr 11L 1c. (Use of crushed rock will not be permitted for backfill if contact will be made between <br /> the backfill material and taitks/pipes made of poly Min glass of 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 desrnbed above will be placed at a minimum of five (S� cubic yards per 1000 gallon ;air <br /> dispiacemem and that the cut re excavation will be backfilled and compared to asure comPliaace with the Uniform Buildiag Code <br /> Appendix Chapter 70. <br /> Oak <br /> c ( tint <br /> Ra JCS Ssis eIj <br /> e <br /> e <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />