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11/02/2001 10:47 9166813 31 <br />GEOFON INC <br />BACKFILL EXCAVATION CERTIFICATE <br />Contractor__&� Phone <br />PAGE 14 <br />.,p X1911 ��.Jt <br />LV fi. <br />License No. <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />L`/I. Submission of Soil Engineer's Compaction Report within 30 days of Miect aQmpleti(nn, or <br />✓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 />A. Yea grAvel--smooth, rounded material not snore than one-half (1/2) anis in diameter <br />✓B. Crushed rack--s®lf-compacting material not more than t> e.q crantaci will I� Inch madelaetweethe <br />sectional <br />measurement, (Use of crushed rock will not be for backfillif <br />backfill material and tanks/pipes made of poly resiin glass or similar materials.) <br />)DECLARATION <br />1 hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 Clays Qf eject eampledon, or submission of <br />verification that the select he e m t r al de criion wall bo backfilled 'Placed tzrpsCt minimum to GomplianCe with the UtEiforper at Building Code <br />Qisp�cement and <br />that <br />Apptndix Chapter 70. <br />ame <br />* Al <br />a <br />tgnatuze <br />s Shall be the responsible managing etttployee on the license or authorized agent. <br />