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BACKFILL EXCAVATION CERTIFICATE <br />Project Location <br />Owner CH Ow P V-019uG- e-, cip-+ Phone No. 510- <br />Contractor t�;El�Di # �0�%5 �v�5 '^Phone No. 20�-.511 %- License No. 2 '3 <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />_// 1. Submission of Soil Engine`r'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 />ve"'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 truss 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 />It • <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 1Ck)0 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 />* Ke -'A^ . a- W eAIA- <br />Name (Ynnt) <br />GoM�57'leutx70d <br />t (Prinv <br />tgnatutre <br />* Shall be the responsible managing employee on the license or authorized agent. <br />