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BACKFILL EXCAVATION CERTIFICATE <br /> _ 1 ^ <br /> Project Location 2 o nGG s F4,5) E8R ,, oo( s4fP et y S T�.,C J<TOn � 6'T <br /> Owner 719A . FRnie E"i&NoPhone No.(Za)) 7 q- 0 Y <br /> - Contractor_ \)PAKi J) I Phone No.(Zo(j) I/67- /QOM License No. 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 /> X2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br /> 74 placed in the excavation in 12' life: <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 <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 submined 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 /> Aqame ( rmt <br /> a e i c <br /> u e ( rmt � <br /> Si re <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />