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3ACKFILL EXCAVATION CERTIFICATF <br /> Project Location 9Z7 BG4C4G D//i/ladD Lacy , 4OD/ y, C4 . <br /> Owner Phone NoC2oy) 333-030 Z <br /> Contractorl&fw Phone No(Z1&) „-SZ/7 License No. 7940360_3. <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 11 Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> ✓ 2. Submission of verification, e.v 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 /> _k-'IB. 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 /> ?-NEa2E �5 CG64a-1 Saiz- Ree E 0,4-15/725:7 /%avy glzApiv� 4477; <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 das 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 /> ame krumv <br /> q� tt a (Print) <br /> * r'! <br /> SignaLUM <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />