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,2/20/2006 12:49 2094640138 ENVIRONMENTAL � `LTH PAGE 11/11 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: 2or%q � cTu <br /> Owner: Phone No:,F<9't 9q 1 31 OCA. <br /> Contractor: srgk,. Srn. -A 9 c Phone No: 26l?-�{ <br /> License No: 09 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> �2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> one/of the following materials was placed in the excavation in 12" lifts: <br /> �A. Pea gravel--smooth, rounded material not more than one-half (1/2) <br /> inch in diameter <br /> _B. Crushed rock--self-compacting material not more than three-quarters <br /> (3/4 inch in cross sectional measurement. (Use of crushed rock will <br /> not a permitted for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin glass or similar <br /> materials.) <br /> DECLARATION <br /> hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> of pproject completion or submission o))f CvCerification that the select material described above <br /> thaltbhe ie excavation will bevbac(dilledi andcompacted0toensure compliance wthahe <br /> Uniform Building Code Appendix Chapter 70. <br /> PLoeS <br /> ame nn <br /> L <br /> nage <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />