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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 540 W. Park St. , Lodi CA <br /> Phone No. <br /> Owner Bill Reich (209)334-2354 <br /> Contractor JIM THORPS OIL, INC-I— <br /> INDICATE <br /> No. (209)3b8-6175 License No.495699 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 2. Submission of verification, e.g., load lifts.icket,within 30 days of project completion that one of the following materials <br /> was placed in the excavation 1 <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 <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> ction ct <br /> or <br /> sion <br /> I herebycertify th ta Soil the select material ompdescrahed at ve wrill be p1 ced atbe ta m nim m of fted within 30 ive(5�us oflb c yards per o1000 gallontank <br /> of verifcation that <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 THORPE OIL,INC. <br /> ame ( rint) <br /> *=ignature <br /> I e 1`1* <br /> Shall be the responsible managing employee on the license or authorized agent. <br />