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Project Locatiea <br />Owner <br />BACKPILL EXCAVATION CERTIFICATE <br />Puerile No <br />ConTac:or <br />Phone No. License No. <br />INDICATE METHOD Or 3ACKFILL QUALITY ASSURANCE <br />Submissiess of Soil Ettgiaser's Corm cl Repor. w°thin 3o days of project com cr-on, or <br />Sui tnissien sof vcrifI=.cn, e.g., load ticket, within 3C days of project comp cion that one of the foIlow•in; tr3terials NQ <br />placed in the excavation in 12" lifts: <br />_ A. Pon gra%,el—s;noot. , rounded material not more thv, one-hzJ;U2i inch in di=ete. <br />B. C:ushod rock--self-compacting material not mere than luee-quartzrs (3; 4) inch ",n cress sectional <br />measureert. (Use of enished rock � U not be rermned for •backnll if cott <br />mtact willbe trade be^Leon <br />the backfill material and tanks/pipes made of w . resin glass ar similar materials.} <br />DE.CLAPU i°ION <br />1 hereby certify diet a Soil n;i. 's Compatriot. Report will be sybmittei •xithin 30 days of project coMpietion. or s ibmissior. of <br />verification Char the select material desc:bcd above •xnli be piaced at a tat.ni= of ;rive an vu it yards if l b ,Alen tank <br />displatezteat and that the entire excxvaricn will be backfilled and ccmpacted to inure compLaace with the Uniform Butldirg Code <br />,k- <br />.ppendi, Cbapter 70. <br />+arneru.:; <br />Title C rant; <br />tunatur= <br />" Saali 'ae the r espo:uibie :nana,ina err riovee or. the ,-.cerise or actho. izec agent. <br />