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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location, `t T G1 \M/ UNIG(P>4L P<IK?f)?T / <br /> Owner CA DP-I C Phone No. ZOq —9i 51&l 4� b <br /> Contractor C,(Z-y Mc, . Phone No. "610-2612--372-6License No. <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 verification, e.p., load ticket,within 30 days of project completion that one of the following materials <br /> was placed in the excavation in 12" lifts: <br /> A. Pea gravel--smooth, rounded material not more than one-half(12) inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quartets (3/4) 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 Report will be submitted within 30 days of roject completion,or submission <br /> of 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 <br /> Code Appendix Chapter 70. <br /> * SHPcN� .KINI <br /> ame (Print) <br /> u e (Frin <br /> * <br /> —Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> i <br /> L <br /> i <br /> e <br /> a <br />