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'A"FILL EXCAVATION CERTIFICATE <br />Project Location V / <br />Owner — f t ,Jbone No. 7o7— Zy Z37to <br />Contractorjnd,;,gn(F�J Phone No. Zoy-%_)-Jy0lr _License No.&AO 2Z-7 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />x2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br />T placed in the excavation in 12" lifts: <br />XA. Pea gravel --smooth, rounded material not more than one-half (1/2) inch in diameter <br />7� B. Crushed rock—self-compacting material not more than three-quaners (3/4) inch in cross sectional <br />measurement. (Use of crushed rock will not be permitted for backfill if contact will be made between <br />the 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 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 />��t� �uEIIAR <br />—dame ( rmt <br />�fia,CCt l3P�IriS7 <br />Tignar <br />t e ( rmt <br />* Shall be the responsible managing employee on the license or authorized agent. <br />