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CKFILL EXCAVATION CERTIFICATE <br />sT <br />Project Location_ <br />Owner M tits '4' C,b({iLt/ L, /1y LfJ oe_ Phone No. Zag - IP -3p - _74' /_j <br />Contractor_,:; Cc> Phone No. 709-5_2-tF-i(5_3 License No. L/owLy <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 />e4- A. Pea gravel --smooth, rounded material not more than one-half (1/2) inch in diameter <br />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 Building Code <br />Appendix Chapter 70. <br />Name (rrmt) <br />+ F -D 2 4-v t3 <br />n e int <br />+ <br />amre <br />* Shall be the responsible managing employee on the license or authorized agent. <br />