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BACKFILL EXCAVATION CERTIFICATO <br /> Project Location—Jr->Er 4 f= V t C��-sr � L p t�h -r Lp,N F—- S-LI <br /> LC <br /> Owner I Ct�tc C-�4S .o �. C Cot�nPaa'y._. Phone No. fQI 1S� 4'I3 —'Irl t� <br /> Contractor 5T0c_TOQ SEPyK.E t'�o,,A Phone No. (Z,69)4&4—Jk3 3 License No. <br /> E&Qi is MST GO.3 Tt4c . C3�o NAS <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" lifts: <br /> r.! 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 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 hereby certify that a Soil Engineer's Compaction Reportwill be submitted within 30 days of project 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 /> me (Print) <br /> Title rm <br /> tg ture <br /> Shall be the responsible managing employee on the license or authorized agent. <br />