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Z <br /> K <br /> --?z— a <br /> QJOA <br /> BUMOW SWAM now*0*4ft4nd <br /> DFLANWG ROM ON 488-M20 . <br /> KMMMCMM*46&3t23 <br /> NBOHM=PRMBNAWN FrIoNr=mM 4w3o2i <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Pro act Location VT,%%%,Qv rma M-Le Lpw b Z%33 4 W. Ste, % 5 Tw�j-'ZA QFk 'Chs-tWa <br /> Owner t-,)Przw,%f- \4%t3r. vVT Phone No. kr <br /> sl cs-3ZC4 <br /> Contractor V'jk%G%xr gdgv. S%ts.7Qr, Phone No.(� 833-OnSS License No. GCJ -TO <br /> nWXCA= M=OD OF ZAC1QWZ QM== ASSURANCII <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion, or <br /> 2. Submission of verification, e.g. load ticket, within 30 days of project <br /> completion that one of the following materials was placed in the excavation in <br /> 12 lifts: <br /> A. Pea gravel - smooth, rounded material not more than one-half (1/2) <br /> inch in diameter. <br /> a. Crushed rock - self-compacting material not more than th-ree-quarters <br /> (3/4) inch in Cross -sectional measurement. (use of crushed rock <br /> will not be permitted for backfill if con'-act will be mad* between <br /> the backfill material and tanks/pipes made of poly resin glass or <br /> similar materials.) <br /> DECLARATION <br /> I hereby certify that a Soil ZngLaeor's Compaction Report will be submitted within 30 days <br /> of project completion, or submission.-of verification that the select material described above <br /> will be placed at a minimum of five -(5).:'cubic-yo-ar4s�:per 100(Y gallon tankdisplacement ii:d <br /> . <br /> that the entire excaration-wLll-'b6-bjjC-!d-LIlid-ijid-ciacted to L"%ijj --*rLth the <br /> 4 <br /> Uniform <br /> " -g pg.BuLl14 4--Code'Appendf Chap'tier70. , <br /> . 4rT, <br /> Lq <br /> w44 <br /> TaAl (Print) <br /> Si. at a <br /> Shall be the responsible managing empal <br /> ea.on the license.or authorized ..-. <br /> ali,int 7. <br /> �Wv I­LC/WC3=.D= <br /> 4ib, <br />