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BACKFILL EXCAVATION CERTIFICATE <br /> Protect Location <br /> 2449 W. Kettleman Lane, Lodi, CA 95242 <br /> Owner Jams Anagnos Phone No. (209)333-1036 <br /> Contractor JIM THORPE OIL. INC. Phone No. (209)368-6175 License No.495699 <br /> INDICATE ME'I'11OD OF BACKFILL QUALITY ASSURANCE <br /> _ L Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 2. Submission of verificatlon, e.g., load ticket, within 30 days of project completion that one of the following materials <br /> was placed In the excavation in 12" lits: <br /> X 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 (314) 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 Soll Engineer's Compaction Report will be submitted within 30 days of rojecl completion,or submission <br /> of verification that the select material described above will be placed at a minimum of five (5�cubic yards per 10011 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OILnINC. <br /> ame r nt <br /> • CON'rRACT0 <br /> �'em' <br /> • Signature <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br /> i <br />