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`/ / n <br /> Project Location / �/�f5 k) `5V_ Or Q.S l�cl �.O cj,; �.A <br /> Owner�A L % , Phone No. q(aq — Qq Ll L4 <br /> Contractor, ,4*s LURL.ne —A2cc_T_ r- Phone No. Sr Lcc l sn b License No. to 5 53D ) <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. _ 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 /> 1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days 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 /> • A9� <br /> Name rent <br /> itle(Frin <br /> Signarafto <br /> • Shall be the responsible managing employee on the license or authorized agent. <br />