Laserfiche WebLink
BACKFILL EXCAVATION CERTIFICATE <br />Project Location a O D C) S1fi' M S o H leo 4 W r -9 -Jv e Lz -/10 N , f R 95dy <br />Owner ;/,'4 -ex qpr4e , S�oc /5-d11 191ME Phone No(,90g) 111 ®.1'33 I <br />Contractor Phone No/5.30)-7-(/5--8S-6:L License No. A-7/S'oR 7 / <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />X 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 />k A. Pea D avel--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 ro'ect completion, or submission of <br />verification that the select material described above will be placed at a minimum of five (5cubic 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 />Name rent <br />PCy,'e­f lV4ntides- <br />'I"i e t _ <br />signature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />S.J. <br />