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,".CKFILL EXCAVATION CERTIFICATE 1./ <br />Project Location 3 6 S jr. ///h S%, , % KAC j/ � 95 .3 7 <br />Owner C r T y OF 7-9,4 C y Phone <br />Contractor -WR I Cr 14 T Fgy i K0 ✓ Phone No.20l- 93'? -07S-8 License No.—Af &, HA7 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />y 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 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 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 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 But Code <br />Appendix Chapter 70. <br />* a E FF �owNs <br />Name (rrmt) <br />* YR-03tCT htAk)AGEf_ <br />T; rmt <br />Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />