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r <br /> BACKFILL EXCAVATION CERTIFICATE <br /> �9 <br /> Project Location Teresi Trucking 900 112 E. Victor Rd. Lodi 'h CA <br /> F <br /> Owner_ Teresi Trucking __ _Phone No. (2 <br /> Contractor JIM THORPE OIL, INC. Phone No. (209)368-6175 ! License No.495699 <br /> INDICATE METHOD OF BACKFILL QUALITY�'ASSURANCE <br /> Ih <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, of <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials <br /> was placed in the excavation to 12" lifts: E <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 thanijthree-quartets (314) 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 or poly resin glass or similar materials.) .. <br /> DECLARATION <br /> I hereby certifythat a Soil Engineer's Compaction rteport will be submitted withiri;30 days or project completion,or submissiion <br /> of veriFicationthat the select material described above will he placed at a minimui'rt of Gee(Scubic yards per 1000 gallon <br /> tan <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 /> i • JIM THORPE OIUYINC.., <br /> ame ( rtnt) <br />� r <br /> • CONTRACTOR <br /> gt <br /> tgnatur <br /> J1 <br /> Shall be the responsible managing employee on the license or authorized agent. <br /> �F <br /> 'IY <br /> 1 <br />