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' 4CMU EXCAVATION CERTIFICATE <br /> Project <br />' r "~ phone No. <br /> actor — L i 0 �C - Phone No - License No <br />'S l►���oN kQu k� co 1 N C -- <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ i Submission of Soil Engineer's Compactton Report within 30 days of project completion, or <br /> 2. Submission of verification, e' $ , load ticket, withm 30 days of project completion that one of the following materials was placed in the excavation m 12 lifts. <br /> A Pea gravel—smooth, rounded material not more than one-half(1R) tach m diameter <br />' 0- 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 ject completion, or submission of <br /> venficatton 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 tonic compliance with the Uniform Building Code <br /> Appendix Chapter 70 <br /> * SE <br /> lo <br /> r4ame not <br /> * kt—N FU 11 N ER <br /> ie <br /> I * <br /> Signature 97 <br />' * Shall be the responsible managing employee on the license or authorized agent <br /> I <br />