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• BACKFILL EXCAVATION CERTIFICATE <br /> Project Locationl 'T511 �a-um G r+V`,- I c /� <br /> Owner 'f W Phone No. 00q- '75112A:, <br /> � e <br /> Contractor VQ. u eh ql rte 'E.I'j 1LI Phone No.UQ -q(A"2014 License No. 811612- A N z_ <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> 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 /> DECLARATION , <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of roject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five ( 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 /> * C, A.a4 C.f�lq I►�leP.l't�1 d1 tb�'taQ.� Un'(le 1 I <br /> Name(Print <br /> * r-4-.e r- <br /> it a(Print) <br /> wa— <br /> //L45igAalure <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> I <br />