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' 1/ BACKFILL EXCAVATION CERTIFICATE <br /> Project Location -(Ll b C'O /7 � <br /> . c �/V 4 W 4 M t CA <br /> Owner. P4,Vl�CC1 l (7aii l �j( t-L , Phone No� <br /> Contractor SI21CO Phone No. (209) 524-9653 License No. 449864 <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 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. <br /> V'11 <br /> ame t <br /> I [ <br /> gnature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />