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0KFILL EXCAVATION CERTIFICATE • <br />Project Location / /-t2(/ iv , wr v .I <br />C Phone No. 7 ) <br />Owner /�7 1��°/ <br />Contractor��//�/Iy`%% Phone No&t Y,/�TV /' License No. g BJZZ% <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.Fload ticket, within 30 days of project completion that one of the following materials was <br />placed in the excavation in 12 lifts: <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 />rmitted for backfill if contact <br />the backfill nmaterial and ctanks pipes made of poly rushed rock will not be resin glass or similar materials.) will be made between <br />DECLARATION <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of pproject completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (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 Code <br />Appendix Chapter 70. <br />qipirn <br />'t/m <br />* Shall be the responsible managing employee on the license or authorized agent. <br />