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L <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project laxation Reilly's Car Wash 100 E. Lodi Ave. , Lodi, CA 95240 <br /> Owner Kevin Reilly Phone No. (209)334-6144 <br /> Contractor JIM THORPE OIL, INC. Phone No. (209)364-6175 License No.495699 <br /> INDICA'PE METIIOD OF BACKFILL QUALITY ASSURANCE <br /> _ L Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> X 2. Submission of verification, e.gg., load ticket, within 30 days of project completion that one of the following materials <br /> was placed in the excavation in 12" lifts: <br /> X 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 perchy certify That a Soil Engineer's Compaction Report will be submitted within 30 days of roject completion,or submission <br /> of 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 <br /> Code Appendix Chapter 70. <br /> • JIM THORPE OIL,INC. <br /> Name r nt <br /> • WN'I'RAC ' <br /> e n <br /> Ignature <br /> • Sball be the responsible managing employee on the license or authorized agent. <br /> I <br /> i <br />