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BACKFILL EXCAVATION CERTIFICATE <br /> i <br /> Project t ocalion 25433 Fxutiee Rd. , Acamno, CA 95220 <br /> Owner The F'annip Map Fohmdatinn Phone No. (2n9)2'A5-202n <br /> Contractor JIM THORPE OIL, INC. Phone No. (209)36MI75 License No.495699 <br /> INDICATE MEI'IIOD 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 flim one of the following materials <br /> was placed In the excavation In 12" lifts: <br /> X A. Pea gravel--smooth, rounded material not more than one-half(I/2) Inch in diameter <br /> B. Crashed rock--self-compncting 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 <br /> I berchyy cettfy thni a Solt Engineer's Compaction Report will be submitted within 30 days of roject completion or submission <br /> of vetficaton that the select material described above will be placed at a minimum of five(5Mble yards per 1600 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to Insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> • JIM TIIORPE OIL,INC. <br /> Name (Print) <br /> • LON'1'RA <br /> Ile <br /> Signature <br /> • Shall be the responsible managing employee on the license or authorized agent. <br /> i <br /> i <br /> i <br /> , <br /> ' I <br />