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eb . B . 2005 2 : 31PM No - 3449 P . 11 <br /> • BACKFILL EXCAVATION CERTIFICATE 0 <br /> Project Location:a ksL /b{Iq(6g4,Aw"'. 410.4 y o 64, TS-3710 <br /> Owner, ly-*01LIS Phone No: / �t <br /> Contractor. hJerPhone No: r p — —1License No: „f <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,F,, load 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(1/2)inch in diameter <br /> ALB' Crushed rock--scif-comPactliq material not more than three-quarters (3/4) inch in cross sectional <br /> measurement. Wooacerm <br /> hoebFll mnf r1A� '} - r e <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 dayys of roject wmpletion, or submission of <br /> verification that the select material described above will be placed at a minimum of 5ve (� cubic yards per 1000 gallon tank <br /> ' Aendixdisplacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform But Code <br /> Appendix Chapter 70. <br /> ams nn <br /> • r t5 <br /> ' I e t <br /> tgneture <br /> Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised )D/16/03) <br /> Page 11 <br /> 1 <br /> 1 <br />