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4 <br /> i <br /> BACKFILL EXCAVATION CERTIFICA'T'E <br /> Project Location <br /> Owner .D�. Phone Na. <br /> Con tractor,�L'��`- 1 Phone No. i � License No. � b r� <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the foIIowing materials was <br /> placed in the excavation in 12" lifts: <br /> A. Pea gravel--smooth, rounded material not more than ane-half(112) inch in diameter <br /> �. B. Crushed rock--self-compacting,material not more than'three-quarters (314) inch in .cross sectional <br /> measurement_ (Use of crushed rock will not be permitted for backfill if contact will be made between the <br /> backfill material and tanksipipes 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 project 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 /> Name (Print) <br /> e( t <br /> * <br /> afore <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />