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Project Location <br />Souza <br />F4 <br />VATION CERTIFICATI� <br />g, 612 W. 11th St. Tracy, C, <br />Phone No. (209)835-8330 <br />Contractor Jim Thorpe Oil, Inc. Phone No. (2O9)368—Fi775 License No.gra5acia <br />INDICATE METHOD 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.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 />X A. Pea gravel --smooth, rounded material not more than one-half (112) inch in diameter <br />_ B. Crushed rock—self-compacting material not more than three-quarters (3/4) inch in cross sectional <br />tmeasurement. (Use of he backfill material and ctanksipTestaadcof poly rushed rock will not be permitted <br />glass f or smidar atenals-or backfill if j will be made between <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 Building Code <br />Appendix Chapter 70. <br />* Richard Th <br />Name (Print) <br />* Contractor <br />I el <br />7gnature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />