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CKFILL EXCAVATION CERTIFICATE <br />Project Location l0 C.lN S L N a i; L E UJ\1 S710 C 42 U o C A g J 2 C) S <br />Owner S NNI ()N;i 1\ 1 C o m,7 \( Phone No. <br />Contractor S%U CWi OAI SER \j \ C E Phone No. 6 - 8333 License No.A,4n ta AZ <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.p , 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. Pea gravel --smooth, rounded material not more than one-half (1/2) 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 />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of pproject 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 />ame rtnt <br />Fu Z <br />-1 itle rent <br />* d rt- <br />- <br />signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />