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RECEIVED <br /> r.rR 2, 0- 2018 <br /> ENVIRONMENTAL <br /> JH DEPARTMENT <br /> BACKFILL EXCAVATION CERTIFICATE' <br /> Project Location: )_5 7-1 L-0 6C) Ci , TC(k <br /> Owner W i ck �j ,r��o,� , l�c�} ;�a'�r, I Tei r t lk:�;;� Phone No: `31C) <br /> Contractor: Lo A';od.(1n,L Phone No: <br /> License No: SC)LA q.0 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2. Submission of verification, e.g:, load ticket, within 30 days of project completion that <br /> one of the following materials was placed in the excavation in 12" lifts: <br /> _ZA. Pea gravel--smooth, rounded material not more than one-half(1/2) <br /> inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quarters <br /> (3/4)) inch in cross sectional measurement. (Use of crushed rock will <br /> 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 <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> ofproject completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> *Name (u l ka-r 1S <br /> (print) <br /> Title ock-f(".h cou Ycl i slca-6 i.iS'i S.Cru c1'S <br /> � (Print) <br /> Signature C_ <br /> *Shall be the responsible managing employee on the license or authorized agent. <br />