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BACKFILL EXC�AV11ATION CERTIFICATE <br /> Project Location l goo S O lKl�k',w�� y—.t <br /> Owner &AyLi, c>n7yt217 Lt, "gr Phone No.cgcp f-- X183 -D5?5- <br /> ContractortypLLA,,,u YGLLOt'&.em emnr• Phone No. 630_ j7f3yafj3 License No.(o917-_38 /-b <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.§-, load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12 ifts: <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 /> 1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 da s of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of f ve (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 /> *�r� c,1 SCSI 1 <br /> Name rm-T)- — <br /> *� not � PC- 7Z Cl V-) c <br /> ipe ignature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />