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- BACKFILL EXCAVATION CERTffIFICATE <br /> Project Location !to( ( Dolrado btl�Tr3✓t <br /> Owner Zeb k1A in Phone No. -Zv5 ) gpj& ' 117S; <br /> Contractor SEMCO Phone No . ( 209 ) 524- 9653 License No. 449864 <br /> I _ <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 following materials was <br /> placed in the excavation in 12" lifts : <br /> I <br /> X A. Pea gravel—smooth, rounded material not more than ane-half (1/2) inch in diameter <br /> B . Crushed rock—self-compacting material not more than three-quarters (3/4) inch in cross sectiowa <br /> measurement. (Use of crushed rock will not be permitted for backfill if contact will be made betwee. <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 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 tark <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Cod= <br /> Appendix Chapter 70 . <br /> * .�� l a "A <br /> ame(Prm—[ I <br /> « 0 'eY <br /> t enrent <br /> amre <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />