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..i <br />I BACKFILL EXCAVATION CERTIFICATE <br />Project Location: elci V, fr Ur4e(� S foC,kfon <br />Owner: I)n,*irsfC�rp fofeo /l Phone No: :207 -7y1 -P 36�( <br />Contractor: Eny1ro11AtBe4a1 "Incenll� Yconf/ath, Phone No: �fq 467--Z30c' License No: 4042—7-y3L267 <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 reject completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (i� 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 />ame rtnt <br />tgnature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />