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V 71�1�1 �rp <br />*wner � b 'L, Lo V�N44 Phone No. <br />Contractor Phone No. License No. <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 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- carters <br />(3/4) inch in cross sectional <br />measurement. (Use of crushed rock will not be permitted for backfin if contact will be made between the <br />backfill material and tanks/pipes made of poly resin glass or similar materials.) <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 ata minimum of Zvse (5) cubic yards per 1000 gallon tank <br />displacement and that the entire excavation will be backfffled and compacted to insure compliance with the Uniform Building Code <br />Appendix Chapter 70. <br />Name (Print) <br />nue Trint) <br />51pature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />