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SANJ O A Q U I N Environmental Health Department <br /> --- C O U N T Y --- <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location : <br /> Owner Phone No : <br /> Contractor : Phone No : <br /> License No : <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1 . Submission of Soil Engineer' s Compaction Report within 30 days of project <br /> completion , or <br /> 2 . Submission of verification , e . g . , load ticket , within 30 days of project completion <br /> that one of the following materials was placed in the excavation in 12 ' lifts : <br /> A . Pea gravel --smooth , rounded material not more than one- half ( 1 /2 ) <br /> inch in diameter <br /> B . Crushed rock--self- compacting material not more than three- <br /> quarters ( 3/4 ) inch in cross sectional measurement . ( Use of <br /> crushed rock will not be permitted for backfill if contact will be made <br /> between the backfill material and tanks/pipes made of poly resin <br /> glass or similar materials . ) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 <br /> days of project completion , or submission of verification that the select material <br /> 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 <br /> compliance with the Uniform Building Code Appendix Chapter 70 . <br /> * Name <br /> ( Print) <br /> Title <br /> not <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent . <br /> 10 of 10 <br />