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AC LL EXCAVATION CERTIFICATE <br /> n <br /> Project Location�Qol sn c� �- �JQ��M � V4 rr <br /> Owner b 'Y� K a *..Pq-d— Phone No.yDq— q6q/ 6 .347 <br /> ContractorSrik. , 2>.2Q . STA • & G;i1 Phone No . L�q— t [ 6t{ �T License NoSod( / O c6/ /yyott4 — <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> �1 . Submission of Soil Engineer' s Compaction Report within 30 days of project completion, or <br /> 4� 2 . Subm ssion of verification, e . g. , load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the ex vation in 12" lifts : <br /> _ 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 /> * _ ✓Ill'-� �/'-�S <br /> I�am�rmt <br /> nigna:p" <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />