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BACKFILL EXCAVATION CERTIFICATE <br /> i <br /> Project location 4147 S El Dorado St Stockton CA 95206 <br /> Owner Van De Pol Enterprises Phone No. (209)466=5921 <br /> Conlraclor JIM THORPE OIL, INC. Phone No. (209)368-6175 License No.495699 <br /> i <br /> INDICATE ME'1'IIOD 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.gg., load ticket, within 30 days of project conieledon that one of the following materials <br /> was placed in the excavation In 12' Nps: <br /> X 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 /> mensuremerir. (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 /> 1 herebyy cel itfy join a Solt Fnglneer's Compaction Report will be submitted within 30 days of roject completion,or submission <br /> of ver Ificalion that the select material described above will be placed at a minimum of five(5�cubic yards per 10011 gallon lank <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OIL, C. <br /> Name r nt <br /> • COWL'R <br /> It- <br /> Til r <br /> gnature <br /> • Shall be the responsible managing employee on the license or authorized agent. <br /> i <br /> I <br /> i <br /> I <br /> • I <br />