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11ECEIVE <br /> BACKFILL EXCAVATION CERTIFICATE MAR 16 2015 <br /> Project Location: j �J jam` O� ��C� ENVIRONMENTAI <br /> 1 Tt rpP�7T1.7cR'T <br /> Owner ✓IJ gf ") Phone No: �2_05 <br /> Contractor: OQ� �J/l/�✓C. Phone No:' �L.f�] r <br /> License No:_ 5 doj� �j9Z, 1 Y <br /> APR 2 4 2015 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCENVIRQNMENTAL <br /> HFA'TW r)coeonecniT <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(1/2) <br /> inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quarters <br /> (3/4) 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 /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> of Project 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 x,41,1G'�c'/ <br /> n <br /> Title ) l( <br /> OX' <br /> nn <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> � 3 <br />