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10 CKFILL EXCAVATION CERTIFICATE <br /> Project Location Wo5 W05 <br /> `'t vw s orcttb <br /> Owner AC!Fl c, COg� uU14Sf� g 0 JP",, Gm Phone No. 9QJ— y 1 e• 5 54 y <br /> Contractor6�yANCRA Gey, Phone No. 2mq 1167--10o& License No. 6SO 927 - <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 /> _4A. 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 <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 of <br /> verification that the select material described above will be placed at a minimum of five (S) 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 /> *_777/Z7,,,4 <br /> C !A <br /> Name rent <br /> _P0,* o Jwr G e to <br /> Itle r t <br /> i re <br /> * Shall be the responsible managing employee on the license or authorized agent. <br />