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0 <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: Z51J—W 14AA11VVIA ET- JP410W0� <br /> 4 <br /> Owner. ,��-YN S"wmxr;-,Ti Tw r Phone No: I <br /> Contractor. Phone No:- <br /> License No: <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1.Submission of Soil Engineer's Compaction Report within 30 days of project <br /> completion,or <br /> 2.Submission of verification,e.g., load ticket,within 30 days of project completion that <br /> one of the following materials was placed In the excavation in 12"lifts. <br /> A. Pea gravel—smooth, rounded material not more than one-half(1T2) <br /> .inch in diameter <br /> 9. Crushed rock—self-compacting material not more than three-quarters <br /> (3/4)inch in cross sectional measurement. (Use of crushed rock will <br /> 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 <br /> materials.) <br /> DECLARATION <br /> I hereby certify Report,y that a Soil Engineer's Comaction R rt will be submitted within 30 days <br /> ' It <br /> of t Von or subassion of verification thatthe select material described above <br /> roje, 'mp <br /> wilt be placed at a minimum of five(5} cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to Insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> *Name <br /> (print) <br /> Title 191 ,� �'''".1S°" <br /> ft--ttJ <br /> Signature <br /> ,*Shall be the responsible managing employee on the,license or authorized agent <br />