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f BACKFILL EXCAVATION CER'T'IFICATE <br /> ProjectLocation LAX II--7//�� 5ypy <br /> � \\ n Phone No_M WA. <br /> Owner ,M. `7 y . 5C /2�g'�(� <br /> Contractor <br /> - Ph NoM. 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 /> 2. Submission of verification, e.g., load ticket,within 30 days of project completion that one of the following materials <br /> was placed in the excavation to 12" lifts: <br /> _ A. Pea ;ravel--smooth, rounded material not more than one-half (112) inch in diameter <br /> 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 /> ect <br /> mission <br /> I herebv certify that a Soil Ematerial es Compaction <br /> ibed above will bort le placed at a minimum of five () cl be submitted within 30 days of poulbic yards ds pero1000 gallon tank <br /> of verification that the select <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Buildtn; <br /> Code Appendix Chapter <br /> i a rtnt) <br /> � tt e ( nn[ <br /> Signature <br /> Shall be the responsible managing employee on the license or authorized agent. <br />