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Project Location_.__ 1a -.i('' S'. x_101 #4vE S-r�cC-^ <br />Owner aW t s z4 P MAA4C671S Phone No. 91Q 65-7 — SS-cca <br />Contractor LAI*(_TelrJ 6WG t rJe1,MJ A✓ .* Phone No. `R G ` 37 3 - I ! (ob License No. (-C-7 2-'S8 <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.g., load ticket, within 30 days of project completion that one of the following materials was <br />placed in the y�tcavation 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 <br />ers (3/4) inch in cross sectional <br />measurement. (Use of crushed cock will not be permitted for b 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 soject completion, or submission of <br />verification that the select material described above will be placed at a five of (4 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 />* M I KE LEi< <br />Name t <br />* A4 01 T rtitPo✓ Lcr+LZ�J ✓?� G <br />* Shall be the responsible managing employee on the license or authorized agent. <br />