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FF'Ol,l <br /> TO 19098rF12=14 P.t=11 <br /> j BACKFILL EXCAVATION CERTIFICATE <br /> Prj A <br /> oject Location O t? <br /> O nerII Phone No. q �-7 <br /> C ntractor44 , 8. (_.cJEy Phone "" cJ'C License No. kZ_ 24 9 354 <br /> INDICATC METHOD OF BACKFILL QUALITY ASSURANCE <br /> 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 /> pTced in theexcavationin 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 (3/4) 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 /> l <br /> r <br /> DECLARATION <br /> I <br /> I lereby c�rtify that a Soil Engineer's Compaction Report will be submitted within 30 days of project completion, or submission of <br /> V(riftcatio that the select material deseribzd above will be placed at a minimum of five (5cubic yards per 1000 gallon tank <br /> di placem a[and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br /> A pendix Chapter 70, <br /> ' <br /> me rmtj <br /> � I <br /> I <br /> to - — <br /> �ignarure - <br /> * Shall be the responsible managing employee on the license of authorized agent. <br /> I <br /> I <br /> i <br /> C <br /> i <br /> E � <br /> 1 <br /> I <br />