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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: <br /> Owner: Phone No: <br /> Contractor: Phone No: <br /> License No: <br /> INDICATE METHOD OF BACKFILL QUALITY RANCE <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 tick in 30 days of project completion that <br /> one of the wing materials was in the excavation in 12 lifts: <br /> gravel--smooth, r d material ore than one-half(1/2) <br /> h in diameter <br /> shed rock--s mpacting materi ore than three-quarters <br /> /4 inch in cr ectional measure se of crushed rock will <br /> of be permi or backfill if contac made between the <br /> backfill ma and tanks/pipes ma resin glass or similar <br /> materials <br /> DECLARATION <br /> I hereby certify th oil Engineer's Compaction Report will be submitted within 30 days <br /> of project compl ; 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 enti cavation will be backfilled and compacted to insure compliance with the <br /> Uniform B Code Appendix Chapter 70. <br /> arae (Print) <br /> *Title rin <br /> *Signa ure <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />