Laserfiche WebLink
� � 11 BACKFILL EXCAVATION CERTIFICATE <br /> Project Location -1(�c tri! ts+- 114* 0 0 Ts[Lx=" S �� <br /> Owner _'S_h2_ Phone No.�ga5�7 —9d z3 <br /> Contractor 6XCa,\)4 18A Phone No. blob License No. <br /> -3l - aoay <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 permitted for backfill if contact will be made between the <br /> 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 pinject 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 /> * Name <br /> me ( <br /> ante <br /> r e <br /> >'n <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />