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OB/12/2002 13:19 2094583433 FIFTH FLS PAGE 09 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: <br /> 3O�Z S. t� �2ea,op <br /> Owner — AIS Phone No:ZJc� q vo <br /> Contractor: 55 /SIV Phone No Lice�e No- A ( Z �I S43 <br /> 5rO 7`{"( CY30 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> t <br /> Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> Submission of verification e.,F., 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 tbree-quarters (314) inch in cross sectional <br /> measutemezR. (Use of crushed rock wr71 not be Permitted for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin glass <br /> ass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Sail Engincets Compaction Report will be submitted whbin 30 days of roject completion,or submission of <br /> verification that the select material described above will be paced at a tmnitnartn of five (5� cubic yards per 1000 gallon tank <br /> displacementand at the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br /> Appendix 70. <br /> { g< <br /> Name rine) <br /> ('7 <br /> r <br /> ' Shall be the responsible managing ezaptoyee on the license or authorized agent. <br />