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BACKFILL EXCAVATION CERTIFICATE <br /> Prnject Location: 01- Ct7fj q <br /> k l�� Phone No: ��� 6Z �� <br /> Owner: (� 17-5- 30-7 - <br /> _ r b <br /> Contractor: '(p1` I _7G Phone No: z�7 O -��i License Na: b <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> Y 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 /> 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 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 days of project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5) cubic yards per 1000 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Buffding Code <br /> Appendix Chapter 70" <br /> 7— <br /> ame(Print) <br /> L itle{Print <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 10116/03) Page I I <br />