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T 'KFILL EXCAVATION CERTIFICATE <br /> Project Location KIQZ .156--4 Pvsaet <br /> r.+e.r �, Phone No. t� 8 <br /> o9) 4Sr -7cp <br /> Owner P•5. S <br /> Contractor P:1e Phone NO.Cq'43 G88 596" License No. 73[.787 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 2. Submission of verification, e.fload 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 /> the <br /> measurement. <br /> and tanks/pipes made of poly Use of crushed rock will not be rcs�gl�azsfor <br /> or similar materials.)ll if contact will be made between <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Repoli will be submitted within 30 da s of pproject 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 /> La• ('oto t� ft. <br /> ame rm[ <br /> r <br /> ue trimu <br /> ---signature <br /> " Shall be the responsible managing employee on the license or authorized agent. <br />