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` SAN 1 O A Q U I N Environmental Health Department <br /> COU NTY <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: �CZ ® 7 _ <br /> Owner� ��i�/� i� ���� Phone No:dO 27�=�5 <br /> Contractor. ... /n'1 %_ Z ®�L Ilve. Phone No: �O� - ��� � � <br /> License No: / 2 _ <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE 9 202-0 <br /> 1. Submission of Soil Engineer's Compaction Report within 30 day�6f�'0 �` � l � rH <br /> ce� <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 /> I n <br /> Title <br /> nn <br /> Signature <br /> *Shall be the responsible managing employee on the license or authorized agent. <br /> 1 0 cr= / 0 <br />