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I CICFILL EXCAVATION CERTIFICATE <br /> Project Locanon <br /> Owmcr US?S Phone No.__q t 6Z— <br /> Cont actor It-Q MCO K phone No. (O-3�l Z L cease NO. S I 3 <br /> INDICATE MEI'IiOD OF BACIMLL QQAI-ITY ASSURANCE <br /> _ 1. Submission of Soil Zrgjneer's Contnaicdon Report within 30 days of pmj=eompledoa. or <br /> ✓2. Submission of vcffxxd= a f., load ricket. within 30 days of project compaction mat One of the following materials was <br /> placed ' they tcazua.m 12 lifts: <br /> A. pea gravel-smooth, rounded material not more map ono-half(IM imh is dmmetc: <br /> B. Cr¢shel ick-seif�ompacting tttarttial twt more than three-quarters (;/4) inc ip mss erw: -n <br /> measotemeat. (Use of crushed rockwjU��of <br /> be permitted mor similar materials )wt11 be made bet vr" <br /> r backfill if Contact <br /> the backfll material and taWmlpipes poly <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Repots will be submitted within 30 days of PM"ect completion. or submission c' <br /> verification mat the select material described above will be placed at a =in m„ of nue (5) tabic yards per 1000 gallon :W.:: <br /> dispiac-emeat and ihaz the entire ---cavadon will be backfilled and compared m =sure compliance with rhe Uniform Buildin4 Cx_ <br /> Appendix Chapter 70. <br /> Ss I s a <br /> � "el <br /> w <br /> ' Shall be the responsible managmg employee on the license or audwr=d agent. <br />