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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 'eT,'�`1a-�tf� G <br /> l <br /> Owner '] W ` Phone No. ZOq" 4761-14:7 <br /> Contractor VQ,t uef4VJ1 f1e'of 1 AA Phone No.0 R-4 loy"2014 License No. I 1!o I Z A B A 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. c 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(112)inch in diameter <br /> B. Crushed rock--self-compacting material not more than three-quarters (314) 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 a <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days of project 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 /> * LYl i Meer,A luma, WAC 1! <br /> ame rint <br /> itle rent <br /> tg a re <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> I <br /> a <br /> r . <br />