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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location L�0 '7S • /alai 1.J <br /> Owner J,: v 'C I- 1 I Phone No. 20`('firyd —��d / <br /> Contractor ./OXr.16 % Cern S--r Phone No.—Dq-RmA z-.7 c'r Z License No. 4 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> �. 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 /> 1n. Pea gravel—smooth, rounded material nor more than one-half(1 22) 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 the <br /> backfill material and tanks/pipes made of poly resin giass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days ofpproject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of hve (5) cubic yards per 1000 gallon tank <br /> displacement and drat the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br /> Appendix Chapter 70. <br /> Told s <br /> — Name n[) <br /> r J/L <br /> Titles rmt <br /> Y'�ignature <br /> • Shall be the responsible managing employee on the license or authorized agent. <br />