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BACKFILL EXCAVATION CERTIFICA'T'E <br /> Pm)ectLocation Connell Motor Truck Co. , Inc. , 2211 N. Wilson Way, Stockton, CA 95205 <br /> Same as Above Phone No. (209)466-2411 <br /> Owner <br /> Coulroctor JIM THORPE OIL, INC. _ Phone No. (209)368-6175 License No.495699 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ L Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 2. Submission of veri0cation, e.g., load ticket, within 30 days of project completion that one of the following materials <br /> was placed in the excavation to 12" lifts: <br /> XA. 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 (3/4) inch in cross sectional <br /> lues"retuent. (Use ackfill if contact will <br /> tileabackfill material tand 1lanks/pipes maderof poly tresin dglass for bor similar materials.)be made between <br /> DECLARATION <br /> I bereb certify that a Soil Engineer's Compaction Report will be submitted within 30 da s of roject completion,or submission <br /> of verification that the select material described above will be Placed at a minhmunt of five(5�cubic yards per IOW gallon lank <br /> displacement and that lite entire excavation will be backfilled and compacted to Insure compliance with the Uniform Building <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OIL,INC. <br /> N—amej Hilt <br /> • WN'1'R11C'1' <br /> ti t <br /> ignamre <br /> Shall be the responsible managing employee on the license or authorized agent. <br />