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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 101 SCIJ14 WJ5 , II <br /> Owner F?'7 C/1 J I,(-.a - Phone No. <br /> Contractor AAA sC E d Cts o&viPhone No. y 0o t l2 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" life: <br /> A. Pea gravel--smooth, rounded material not more than one-half(112) 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 perrmned for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin -lass or similar materials.) <br /> DECLARATION <br /> I herebv certify that a Soil Engineer's Compaction Report will be submitted within 30 days ofprojeca completion, or submission of <br /> verification that the select material described above will be placed at a minimum of rive (5) csbic 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 /> _1 <br /> * <br /> Name (P-mi) <br /> * reDg�S <br /> Title(Print) <br /> tgnature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />