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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location y -3-746 <br /> Owner i21S� �Cr �tfi96 Ll2S ;A Phone <br /> Contractgrgj,g, _E&LCOr S.ZIZ Phone 140 - VE41_4R= License No. Yd?fu-1o0' <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> f 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 /> je�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 the <br /> 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 da s 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 /> * <br /> Name (Print) <br /> 1 i <br /> -,Signature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />