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• Envir*ental Health Department <br /> SAN 1OAQIIN <br /> ­—COUNTY— <br /> BACKFILL <br /> .._ COUNTYBACKFILL EXCAVATION CERTIFICATE <br /> Project Location: I-AvZ' DgUi r►c; DP11tK_ s-4ckjavn , Ciq c?5'W7 <br /> Owner _7-&J(e0*, % 'env Z06-sZ Phone No: <br /> Contractor: L.G Servicers Phone No: 1"176 <br /> License No: 7797,67 <br /> 1" <br /> INDICATE METHOD OF BACKFILL QUALITY A SURANCE <br /> 1. Submission of Soil Engineer's Compaction Report ithin 30 days of project <br /> completion, or , <br /> 2. Submission of verification, e.g., load ticket, wjfhin 30 days of project completion <br /> that one of the following materials was P�faced in the excavation in 12' lifts: <br /> A. Pea Qravel--smooth, round�d material not more than one-half(1/2) <br /> inch in diameter <br /> B. Crushed rock--self-co acting material not more than three- <br /> quarters (3/4) inch in ross sectional measurement. (Use of <br /> crushed rock will n be permitted for backfill if contact will be made <br /> between the back I material and tanks/pipes made of poly resin <br /> glass or similar aterials.) <br /> / DECLARATION <br /> I herebycertify that a Soil gineer's Compaction Report will be submitted within 30 <br /> days o project completio or submission of verification that the select material <br /> described above will be pI ed at a minimum of five (5) cubic yards per 1000 gallon tank <br /> displacement and that th entire excavation will be backfilled and compacted to insure <br /> compliance with the Unif rm Building Code Appendix Chapter 70. <br /> *N me <br /> nn <br /> Title <br /> nn <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> 10 of 10 <br />