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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: ��h qy I�t{�' ra )T- <br /> Owner: &1.^(U_ nt{Fi ynu�f}� anfs Phone No: )()I b07 laal <br /> Contractor: AGE PhoneNo:901 °!G7 1004, <br /> License No: /`}µcz b d'0 AZ-1 <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 roject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (� 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 /> * <br /> Name rent <br /> * <br /> Title(Print) <br /> * <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 10/16/03) Page 11 <br />