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FILL EXCAVATION CERTIFICATE <br />P. 12 <br />Project Location k3 _- V1 tv�®r, 120.46 -bj <br />Owner— AFQ J fID,�J `i �i2 e� �F-'.S L� �- C ,q <br />._„ Phone No. / ,-C- 3ZS'=.f-00,0 <br />Contractorl�/9I1AD SQ /IJFC /Z 16tt Phone No. 5/c) — (,/4/—�j �O _ License No. b <br />INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br />e 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 followin" 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. Crashed rock--self-compacting material not more than three-quarters (3/4) inch in cross sectional <br />measurement. (Use of crashed rock will not be permitted for back2ilI if contact will he made between <br />the 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 of project completion, or submission or <br />verification that the select material described above will be placed at a minimum of five (5) cubic yards per 10M 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 />Name (print) - — <br />0 4 ec. 111642. <br />Pr <br />nate -' <br />Shall be the responsible managing employee on the license or authorized agent. <br />