Laserfiche WebLink
BACKFILL EXCAVATION CERTIFICAT` <br /> Project Location <br /> Owner Phone No. <br /> Contractor �'�!/2# 44,P Phone No. oV— 51ff M7 License No. <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion, or <br /> vl"'2. Submission of verification, e.g.; load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12" lifts: <br /> V'A. Pea gravel--smooth, rounded material not more than one-half(1/2) inch in diameter <br /> d. 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 project completion, or submission of <br /> verification 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 insure compliance with the Uniform Building Code <br /> Appendix Chapter 70. <br /> * L o w 7-,�� c/ <br /> Name ( nnt) <br /> * C C7 <br /> We <br /> tgnature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />