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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: <br /> Phone No: <br /> Owner: <br /> Phone No: License No: <br /> Contractor: <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 /> _ A. Pea gravel--smooth,rounded material not more than one-half(1/2)inch in diameter <br /> _ B. Crushed rock--(self-compactindg material not more than three-quarters (3/4) inch in cross sectional <br /> ill if backfill meta. ase of nd tank /s phtpesrock will not of poly a sm glass or ermitted or backfi <br /> rnaterials.)contact will be made between the <br /> DECLARATION <br /> ct <br /> ssion of <br /> I hereby <br /> cetify that a Soil the select material described dt above ion Report <br /> pwill belplaced be submitted inimum of fwithin 30 ive (Ss of�rcubiccyardseper 1000 bga lon 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 /> Name Prurt <br /> * <br /> tt a not <br /> ignature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> EH 23 046 (Revised 3/15/02) Page 11 <br />