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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: <br /> Owner: Phone No: <br /> Contractor: <br /> Phone No: License No: <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> 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(112)inch in diameter <br /> B. Crushed rock--self-compactmg 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 ofroject 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 Building Code <br /> Appendix Chapter 70. <br /> Name Pnnt <br /> Tit e Pnnt <br /> ignature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 7128/06) Page 11 <br />