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�. .� <br /> ACKFILL EXCAVATION CERTIFICATE <br /> roject Location ITJ4)0 5 _,� Q�o &T �+ C <br /> Owner_ <br /> fd�1 <br /> Phone No. Zdl"rhy- 6Q�(o <br /> ContractoLs., 1.54 G i <br /> < Phone No. License No. SCRfOS' <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> �1.• Submission of Soil Engineer's CnnililC[ion Report within 30 days of project completion, or <br /> . Submission of verification, e.g., b_,;:d ticket, within 30 days of project completion that one of the <br /> vation in 12' lifollowing materials was <br /> placed in the excafts: <br /> �l <br /> 7C <br /> A. Pea gravel--smoer::, rounded material not more than one-half(1/2) inch in diameter <br /> B. Crushed rock—sci -compacting material not more than three-quarters (3/4) inch in cross sectional <br /> measurement. (Us„ of crushed rock will not be permitted for backfill if contact will be made between <br /> the backfill mate,:.-_i and tanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Comnac[ion Report will be submitted within 30 days of project completion, or submission of <br /> verification that the select material describe above will be placed at a minimum of five (5) cubic yards per 1000 gallon tank <br /> displacement and that the entire excavation •:!'.: be backfilled and compacted to insure compliance with he Uniform Budding Code <br /> Appendix Chapter 70. <br /> a <br /> * <br /> ti <br /> y t <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />