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SAV JOAUUIN COUNTY 1 <br /> COMMUNITY UEVpI_OF'M f... Up1�Animp-mT r <br /> I0101.11A.Ztt1OI1 AVE,SIOCK10tV.rA 457nS ¢ <br /> t�Zrl,6A UE�Fl.Oh1b1E1►t SE11vICE3 M1011F• (109) 15B J110 I <br /> MAPPM10 r110,IF7 r7n9f 4n11.1}7n <br /> ntm-bR10 r11f)IIE:17991 I6n•3173 <br /> rrEr;1 roOrn Kiov rnESEnvA110F1 r1IpIIF•1t091 Inn 3021 <br /> PACK ILL bXCAVA'TT011 CF;RTIF'ICATN 1 <br />?t.oJecft,oc a L io11 Vailey Wholesale Drug Co. Inc. <br />)wrier Saine as above , .(.209)466-1851 <br /> � alone Nv. <br />,onL1_ac:l:o1_ Jim Thorpe Oil, Inc. P1101le N*�. (209)368-6175 LIcense No: 495699' <br /> IrIVICATE nElW)D OF' mr-Kri w, QUALITY ASSUnMfen <br /> 1 . Stlbml.gg4.ort of Soil Engrineer,4s �CompactloR,`Report within 3U daye�of project <br /> . �, •.._ <br /> compipt ivn ot' '^----- ,�,....,�.-,..,�-..,..�-.�:�=-W=..,-,.-,.•�,�--.T-_-:,�,�_� -.:.-��'._��-"-'"� _ ,�r „v �,�`�.-.»s»:,, - -"..."'�'..,_ - . <br /> 7. . S+tltimi.4g1.oil of Ver. if iratIan, e.q. load ticket, within 30 days of project <br /> campl.etla" that one of the following materials was placed In the- excavation in <br /> 17. ' 1•Lfts1 <br /> t _ <br /> A. r'na gr-ave1. - Ilmooth, rounded material not more than one-half 11/21 <br /> inch in diameter. it <br /> d:. CrI14hed rock - self compacting material not more than three-quarters <br /> .I <br /> (1/4) inch in croqs sectional measurement. (Use of; crushed rack <br /> w1.1.1 not be permitted for backf(l'l if contact will be made between I <br /> the backfill material and tanks/pipes made of poly resin glass or <br /> similar materials. ), <br /> vECLARATI0N. <br /> hereby Certify that a Soil Engineer's compaction Report wlll be submitted within 30 days <br /> pro)SCk completion, or submigglon or verification that the select material described above <br /> Al hP p#.acbd at. a m1.n).r,It1m of flue (5) cubEr_ yar.dfr per lVOO gallon tank displacement and <br /> i;3* tf,e entLre excavntion will br- barkfiiled and compacted to Insure compliance with the <br />'form 130"f1lncg Code Appendix Chapter 10. <br /> '. Jim Thorpe Oil, Inc./Contractor 1 <br /> Richard 'Thorpe <br /> President <br /> (E'rlfit) <br /> ;� Slgriature �: <br /> Shall be lige responsible marlaginc� <br /> agent. employee vn the license or aut'fiorized <br /> . <br /> 1i-L.0/FJtcF.rl7.doc. �, N <br /> i y <br /> i t <br />