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APR-10-2008 05:27P FROM:COPPERFORD-L.L.0 2097279773 TO:4683433 P.1 <br /> RECEI V;, Q.M <br /> ED <br /> < w <br /> APR I 12008 <br /> BACKFILL EXCAVATION CERTIFICATE s N�OROONMENT L <br /> HEALTH DEPARTMENT <br /> Project Location: ���G L.Jl� <br /> Owner: L A G.r eC Phone No: eZ� 7Z7-- 7�a <br /> Contractor: (9DP��✓' �'�Sc3 ��•�.e. Phone No: <br /> License No: 76"3 '9 791 <br /> 1Z5/7.0 Zo=kel- ZZ 44 9 SZ-7 7 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1.Submission of Soil Engineer's Compaction Report within 30 days of project <br /> `f completion, or <br /> 1� 2. Submission of verification, e.g., load ticket, within 30 days of project completion that <br /> one of the following materials was placed in the excavation in 12" lifts: <br /> A. Pea gravel--smooth, rounded material not more than one-half(912) <br /> inch in diameter <br /> ,_B. Crushed rock--self-compacting material not more than three-quarters <br /> (314} inch in cross sectional measurement. (Use of crushed rock will <br /> not a permitted for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin glass or similar <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer'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 yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> 2 Z. <br /> o� <br /> 'Name nn <br /> -Titie7rin <br /> Igpitze- <br /> Shall be the responsible managing employee on the license or authorized agent. <br />