Laserfiche WebLink
ACKFILL EXCAVATION CERTIFICATE <br /> Project Location 9Z7 6k4CAG �Ici�� frig , <br /> OwnePhone NoC�) 333-03o y <br /> Contractors .Lj ���C�'lr�r' Phone NoC7�Orr� a-��� License No. ZF;5 <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.Fload 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 /> �. 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 /> THELE --5 QGEAV0 Soi6 Are,C- o d siTE /52-0i1( (i/ ' �j DoT <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 da s of pproject 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 /> ame rm[ <br /> * .t7 <br /> p n e rm[ <br /> rgnamre <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />