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HAC ML EXCAVATION CEIZSIFICATE <br />~ <br />Be,v+ <br />C 41.E /b <br />nojea%catioa w <br />C % Q <br />Owner <br />License No. 0J <br />^---__..._ %!rte C��.'�'7J �®_or �' �PPhOae No �f!! 'l �% '"�"�=F .•'.. � 9 � "� <br />INDICATE WIETHQA OF BACKPII.L QUALM ASSURANCE <br />1. Submission of Soil Engineer's Compaction Report within 30 Gays of project mrapletion. or <br />Z Submission of verificati0n, e.g.. load ticket, within 30 days Of project completion that one of the following materials <br />W35 placed in the excavation m 12'lifts: <br />A pea gravel smooth rounded matcaial not more than One <br />(1IZ) inch in diameter <br />B, Crushed rock self compacin material not more than three-quarters (3A) inch in cross sectional <br />measurement. <br />�a ement.kall (Use off cru erial and i�,� made E pperatioly sindgless or sor �r7ar materials.) if t a tirade between <br />DECLARATION <br />I hcubic yards per <br />er certify that a Soil Engineet5 Compaction Report will be submitted within 30 daa of roject completio1000 n, or Submission <br />displacementdrilication and hat <br />hat the entire the ScIgg; excavatwalbe cldtiled 'bed atim will be and compacted o laced at a minimum <br />nsure com�iaacet t>Untform�BuilCing <br />,, c Appendix Chapter 70. <br />amt t) <br />sf M �. <br />r era <br />atgnatare <br />Shall be the responsible managing employee On the license or authorized agent <br />Z -d SSSO££60LS CNIdA3NICN3 SV H08A WdZS=Z 9661—ZZ-9 <br />