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CKFILL EXCAVATION CERTIFICATE— <br /> d Z 055 SAS i BR 11100f S ±(eet ST� c /( Ton CA <br /> Project Location r <br /> Owner MA (� RIIJC Fappi & ' `` Phone No. (=CJ9 77y - C93 <br /> Contractor ry tt V gAKQD � Pcfn�r ro nm'rr-F4 � Phone No. (ZQ 9) A l z ZQ01. License No . Q �Z � <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 /> 74 placed in the excavation 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 ranks/pipes made of poly resin glass or similar materials .) <br /> DECLARATION <br /> i <br /> I hereby certify that a Soil Engineer ' s Compaction Report will be submitted within 30 da7s 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 hat he entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br /> Appendix Chapter 70 . <br /> M <br /> tame ( not) <br /> itel q <br /> i t re <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />