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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: <br /> Owner: Phone No: <br /> Contractor: Phone No: <br /> License No: E " " <br /> INDICATE METHOD OF BACKFILL QUALITY,. JRANCE <br /> 1. Submission of Soil Engineer's Compaction Repo in 30 days of project <br /> completion, or <br /> 2. Submission of ification, e.g., load ticke " ithin 30 days of project completion that <br /> one of the Wowing materials was d in the excavation in 12" lifts: <br /> IV <br /> gravel--smooth, rr coed material ore than one-half(1/2) <br /> - indiameter <br /> ushed rock--s mpacting materi ore than three-quarters <br /> /4)) inch in cr sectional measure n se of crushed rock will <br /> of be permi "for backfill if contac made between the <br /> backfill mai 1 and tanks/pipes ma y resin glass or similar <br /> materials <br /> DECLARATION <br /> hereby certify th "Soil Engineer's Compaction Report will be submitted within 30 days <br /> of project comp) or submission of verification that the select material described above <br /> will be placed . minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entir `cavation will be backfilled and compacted to insure compliance with the <br /> Uniform B Code Appendix Chapter 70. <br /> *Name (Print) <br /> it a not <br /> *Signature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />