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4ACKFILL EXCAVATION CERTIFICATE <br />Project Location 'e G <br />Owner 6 ' A' / L � <br />Phone No. /9�.�')� <br />Contractor �A1Z D /%�E'�i/ �G�l G Phone No. (Y/0) G /4� ' �3 `W License No. �y - 9� 2 <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 (lit) inch in diameter <br />Crushed rock--self-compacting material not more than three-quarters (314) inch in cross sectional <br />the <br />measurement. <br />and tanks/pipes ma of poly permitted ill be made between <br />resin glass or similar materials) <br />B <br />DECLARATION <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 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 10. <br />* /role <br />i e rint <br />Ag <br />tgnature <br />* Shall be the responsible managing employee on the license or authorized agent. <br />Z 3!DVd a00 -1J HiJIJ E£V£89b60Z L0:60 0002/LT/90 <br />