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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 3775 Tracy Blvd. Tracy, CA <br /> Owner Cevron U.S.A Phone No. <br /> Contractor TBIf (tY. Psi Le v-A _ Phone No. 13 L` _ License No. 1{ b Z(o I3 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> g 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials <br /> was placed in the excavation in 12" lifts: <br /> X A. Pea gravel--smooch, rounded material not more than one-half (12) 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 <br /> the backfill material and tanks/pipes made of poly resin glass or similar materials.) <br /> DECLARATION <br /> I herebv certifv that a Soil Engineer's Compaction Report«ill be submitted within 30 days ofroject completion,or submission <br /> of verification that the select material described above will be placed at a minimum c {ve (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 <br /> Code Appendix Chapter 70. <br /> ame (' nnt) <br /> • Iitle.( rtnt) <br /> Signature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />