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BACKFILL EXCAVATION CERTIFICATE <br /> project: Location 6425 N, Pacific Avenue St(xkton _ <br /> owner Wiek,�i�d Oil i�one tom. T647R- 485 <br /> Contractor Pile Construction ?Sone 140.916 -5954 License No. 7369r37 Mass <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submtuiou of Sod Engineer'l Compaction Report within 30 drys Of project completion, or <br /> X 3. Submission of verifeatio0, e.F.. load ticket. witho 30 days of project Completion that one of the following matcri3ls was <br /> placed in the excavation in 12 lifts: <br /> _ A. pea gravel__sm0Otb, rounded ttiaterial not more than o"-half(IR) inch iA di&MMr <br /> B. Crohcd rock-self•ccmpacting material not more than three-quarters 1314) inch in cross sectional <br /> measuremeor. (Use of crushed rock tv a of be permitted <br /> for <br /> hackfiim rd if W materials )well be made be ween <br /> he ba.eu material and w*.slpipes teed Poly 1 11 <br /> DECLARATION <br /> I hereby certify that a 5011 Engineer's Compaction Report will be submiaed within 30 da; of pprojecI completion, or submission of <br /> verification the the select auteru) deseribed above will be placed at a ttummttm of five (5) eubtc yards per 1000 ¢anon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure CompBusc wide the Uniform Bu ding Code <br /> Appendix Chapter 70. <br /> ,ben Pile <br /> ante nt) <br /> r <br /> tee( ) <br /> t «ern <br /> Sha)l be the responsible mamaging employee on the license or author d agent. <br /> ES/6'd <br /> E)20_299-0EII-39�M—'f1N-1 -41• 1G-ad 7T-QT a c, •sur <br />