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BACKFILL EXCAVATION CERTIFICATE <br />,.1GG.LL. o � GA <br />Project Location Z'10 ► �. M -� :)Z:z <br />Owner tot�?2o ra L."f-s c,orylP.c>rJ �( c�yn1 a G.� L. Phone No. <br />Contractor VA L,.; 2-4,1t.A Phone No. go �) 3 Z8 l 1 License No. ? 4 <br />INDICATE m=OD OF BACKFILL QUALITY ASSURANCE <br />_ 1. Submission of Soil Engineers 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 M I2 lifts: <br />?c A. Pea ;ravel—smooth, rounded material not snore than one-half (1/2) inch in diameter <br />uarers <br />.e B. Crushed rock—self-compacting (Use crusherock will not be permitted for not more than backfill f c(o3ntact will be made between <br />inch in cross sectional <br />measurem <br />the backfill material and tanks/pipes made of poly resin ;lass or similar materials.) <br />DECLARATION <br />I herebv certify that a Soil Engineer's Compaction Report will be submitted within 30 days of pr cubic yards completion. <br />o submission <br />of verincation that the select material described above will be placed at a minimum of five (5) per <br />tank <br />displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building <br />Code Appendix Chapter 70. <br />0 <br />• Shall be the responsible managing employee on the license or authorized agent. <br />