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BACKFILL EXCAVATION CERT'IFICAT'E <br />Project Location 303 E Kett]eman Lane Lodi CA gS240 <br />Owner Arnie Taylor Phone No. (9ng), .1'ra-145? <br />Contractor JIM TIIORPE OIL. INC. Phone No. (209)3613-6175 License No.495699 <br />INDICATE ME111O13 OF BACKFILL QUALI'T'Y ASSURANCE <br />_ L Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />K 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials <br />was placed in the excavation in 12' IRIS: <br />A. Pea gravel --smooth, rounded material not more than one-half (12) 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 he 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 brie Iyy cerlify 111.11 a Soil Fuginecr's Compaction Report will he submitted within 30 days of roject completion, or submission <br />of verificntion that the select material described above will be placed at a minhumn of true (S�cubic yards per If101) gallon lank <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 1,110RPE (L,INC. <br />14 arae nnI <br />wN'rlt ., <br />rgnaaue <br />• Shall be the responsible managing employee on the license or authorized agent. <br />