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f `` t L.__KFILL EXCAVATION CERTIFICATE <br /> Project Location 6q�6 r AC t r -, c- AUr Si oClf­77 rJ (A <br /> Owner FRED {AK-26D AND L1 8PV AF KTA Phone No. 'J05 <br /> Contractor AIA. CRA 1 C., 'r-0! Phone No. License No. q557-7, <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> v/ 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 xcavation in 12" lifts: <br /> V 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 <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 pproject completion, or submission of <br /> 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 Code <br /> Appendix Chapter 70. <br /> * WIIIIAWI S CtP2t'TJ <br /> Name (Print) <br /> * SAFE_TrooR.DIWATop- <br /> {I\,«a rmt <br /> signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />