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BACKFILL EXCAVATION CERTIFICATE <br />Project Location: /30 S . UII S o VA �,rT sroc%-16v (-,Cl, <br />Owner: Phone No: 2o1 4-? 3 - 7 S 2S <br />Contractor:? -}►T E,vL,11Z4:) rWe-F4c- b yVUM S Phone No: q/(o- kSk -/010 <br />License No: S1Kg D q X /C(4'n : 441L: -to <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 />22. 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 />V A. 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(Print) <br />* Shall be the responsible managing employee on the license or authorized agent. <br />