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• BACKFILL EXCAVATION CERTIFICATE <br /> Project Location C Pf <br /> Owner 2 Phone No. <br /> Contractor e-n I no— Phone No.7o) ���-`J9P(o_ License No. <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-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 glass or similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 da sof project completion, or submission of <br /> verification that the select material described above will be placed at a minimum of Irve (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 Code <br /> Appendix Chapter 70. <br /> Name (Print) <br /> ' <br /> ?r9D\(Zt4 \- IGJnr, Ql� <br /> 1—Tit a rm[[ <br /> signature <br /> ' Shall be the responsible managing employee on the license or authorized agent. <br />