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ti:KFILL EXCAVATION CERTIFICATE <br /> � <br /> Project Location o / ` 0 <br /> AD <br /> ' i 1 2s37A <br /> Owner ,fit — Z ,.�t hone No.�07' � 7 <br /> Contractor fy(wAn(P� �PcFrl�ifct}J1�,1 (Phone No. License No. (0&0 22 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 /> It 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 <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 submined within 30 days of p�roject 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 /> -(Tame ( rmt <br /> * �Ra' Cct U2)rS7 <br /> Me e ( rut <br /> �y <br /> ignavfJ <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />