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BACKFILL EXCAVA'T'ION CERTIFICATE <br /> Project Location t phone Na. 4 <br /> Owner n� O^^r �^e'/fir .� <br /> Contractor� �wDL.I�'1•'O �� phone No. 467 — SCOL License No. (?TO 22Z <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.g., 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 oermitted for backfill if contact will be made between the <br /> backfill material and tanks/pines 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 project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of rive (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 /> —Name l rmt) <br /> *� e <br /> n i e 1 tZnn <br /> Signature <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />