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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location Ty' <br /> Owner 6�IJ I�1� Phone No. 4DE 377 I a83 <br /> Contractor Phone No.-.Iq N-7FI59 License No. "Art UJ-366 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> �1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> V 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in L2' Lifts: <br /> ZA. Pea gravel—smooth, rounded material not more than one-half(112) inch in diameter <br /> V// B. Crushed rock—selfcompacring material not more than three-quarters (3/4) inch in cross sectional <br /> measurement. (Use of crushed rock will not be permitted for backfll if contact will be made between the <br /> backfill material and tanks/pines 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 backdlled and comoacred to insure compliance with the Uniform Building Code <br /> Appendix Chapter 70. <br /> 5 <br /> 1 ( rtnC) <br /> * 151As1`QJ� T C.1�' <br /> 1 e(?ME) <br /> * gaarure <br /> * Shall be the responsfDle managing employee on the license or authorized agent. <br />