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to <br /> BACKFILL EXCAVATION CER'T'IFICATE <br /> Project Location 2512 i <br /> Owner— Mr. Heng Chea Phone No.(2 09) 463 x114 <br /> E <br /> Contractor James J. Hoblitzell Phone Nn. 209 943 7793 License No.365234 "A"Haz <br /> INDICATE METHOD OF BACKFILL QUALITY;ASSURANCE <br /> i <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days ofproject completion, or <br /> X 2. Submission of verification, a g., load ticket, within 30 days of project completion that one of the following materials <br /> was placed in the excavation to 12" lifts: I <br /> X A. Pea gravel--smooth, rounded material not more than oae-half'(1R) inch in diameter <br /> XOIL <br /> .� B. Crushed rock--self-compacting material not more than ll three-quarters (314) inch in cross sectional <br /> measurement. (Use of crushed rock will not be permitted for backfilI if contact will be made betw6en <br /> the backfill material and tanks/pipes made of poly res&glass or similar materials.) <br /> DECLARATION <br />! If <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 dayyss of roject completion,or submission <br /> of verification that the select material described above will be placed at a minimums 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 <br /> Code Appendix Chapter 70. .I <br /> * James J. Hoblitzell , <br /> Name (Print)'. <br /> Contractor <br /> lie (Print) <br /> ji <br /> tgnatllre <br /> s <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> 11 <br /> �I <br /> l <br /> i} <br />