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vlACKFILL EXCAVATION CERTIFICATE, <br /> Project Location 71S f utilgk- Tar( <br /> Owner \/I Ncti j RF a- I Phone No.2 o Q-956-9O/O <br /> Contractor_ -'- GPhone NoLVI-'*q-253,3 License No. 30 F/08' <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 theexcavation in 12 lifts: <br /> 1/ 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 <br /> the 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 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 t Tint <br /> ` ire= ��d4idlsF_/� <br /> We Print) <br /> r t <br /> i <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />