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Aug 22 01 11 : 59a I RCCUTITE 6 952-7631 p• 4 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Projec cation � � <br /> Owner_ – Phone No. <br /> Contractor uC Phone �� QS2'13� License No. ?6120��- <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> V/1- Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> 2. Submission of veritieation, 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 /> A. Pca 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 /> i — 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 glass or similar materials.) <br /> i 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 (S) cubic yards per 1100 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 /> ar to not <br /> It a nn[ <br /> r � <br /> tgnature <br /> • Shall be the responsible managing employee oil the license or authorized agent. <br /> i <br /> 1 <br /> 1 <br /> i <br /> i <br />