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0 0 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location:7647 C*gSZ07 <br /> Owner: SF4T CA-L,�ppW tk Gth%, L*d— Phone No:(S-62)°121 -- <br /> Contractor: 0APhone No- <br /> License No: (s 3f 79 Ate,¢ <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(1f2) <br /> inch in diameter <br /> /B. Crushed rock—self-compacting material not more than three-quarters <br /> {314}} inch in cross sectional measurement. (Use of crushed rock will <br /> 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 <br /> materials.) <br /> DECLARATION <br /> hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> ofproject completion, or submission of verification that the select material described above <br /> will be placed at a minimum of Five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter.70. <br /> 'Name (Print) <br /> Iti --- <br /> i, <br /> *Signature <br /> gna ure <br /> " Shall be the rponsible managing employee on the license or authorized agent. <br />