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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location 4&27 Pa\An4 iye- a 5' oe,k.to ► <br /> Owner Soul nlsad (-Or pora+-icrt Phone No. C111(,) &31-7711 <br /> Contractor Msne�-,!E-, 6otpor'2'forl Phone No.(54,2)595- 4555 License No. 553637 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> _ 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> V 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-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 ofroject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5) 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 /> ��n� •� 5ou�r►I�.nd CO2y40Kutim <br /> ame <br /> * ; 7-M . <br /> ie <br /> * 4� v <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />