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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location <br /> 0._I WT- 0j= Cp&&Z'rl3 <br /> v,0$4 Phone No. �(� /t /- Y/Y/ '� Y23 O <br /> Contractor " Alma Phone No. /G/6 ' Y3/' � License No. &&/.37pD <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.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12" lifts: <br /> _V/A. Pea gravel--smooth, rounded material not more than one-half(Irl) inch in diameter <br /> /B. Crushed rock--selftompactiag material not more than rhrec-quarters (314) 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 /> 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 ItYve (5) cubic yards per 1010 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 not <br /> tt a(print) <br /> mgnatume <br /> Shall be the responsible managing employs on the license or authorized agent. <br />