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�CKFILL EXCAVATION CERTIFICATE <br /> r� <br /> G .J <br /> Project Location Z BM Ea j R etro& Sited r ST-oc tarm �A <br /> Owner MA FAnie Foa iArw Phone No. (M-9) y7y- 0'13q <br /> Contractor 4 J V4AXFO I Phone No.(2Q9) yb 7— /IqO License No. h SO 22 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 74 2. Submission of verification, e.p , 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-quavers (3/4) inch in cross sectional <br /> measurement. (Use of crushed rack 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 pproject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (S) 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 /> * Ji&ffl ` / <br /> i <br /> Name rmt <br /> " u e mt <br /> t re <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />