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0 <br />BACKFILL EXCAVATION CERTIFICATE <br />Project Location L 1- 7() M 5 l C) Q L <br />Owner k u Q(JLAN 7 9 —Phone No. c, 4 - <br />Contractor 5E&j\CE Phone Nok,6"L- - License No. C:-6\ Lo� !2 / iAL6sm <br />SlX--�wm F -,o WL <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 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 the <br />backfill material and tanks/pipes made of poly resin glass or similar materials.) <br />1111*0WO <br />I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days ofproject 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 />-Na—me (Print) <br />kLJE� 4 4_-Or\)—,i�P-,L70'�, <br />Tie tlPrint) <br />OT �5' <br />Signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />