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1We Nue <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location <br />Phone No. <br />Owner <br />Contractor JIM THORPE OIL INC. Phone No. (209)368-6175 License No.495699 <br />INDICATE ME1110D OF BACKFILL QUALITY ASSURANCE <br />_ L Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br />2. Submission or 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" lifts: <br />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 (3/4) Inch In cross sectional <br />tmesurement. Use Of hea <br />abackfill mate al and talnkstpipesed rock wmade of polyill not be rresio glass or sfor imilar mll if contact will be ade between <br />milar materials.) <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of p) roject completion, or submission <br />displacem entnand that the entct ire excavatioerial n will beabove <br />b backfilled and compacted laced at 2 imum Of fiveto insure compliancecubicwith thper <br />e UniformBuilding <br />Code Appendix Chapter 70. <br />• JIM THORPE OILrINC. <br />ame rmt <br />• CUN'1'R " <br />it r nt <br />tgnature <br />Shall be the responsible managing employee on the license or authorized agent. <br />