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BACKFILL EXCAVATION CERTIFICATE <br /> Project Location: /-197Y- <br /> Owner *10/20 10AI'.10,W6) 7,14,,,*,kG,-774. <br /> 39?S'Ownert10/20 ,¢«.10,Wy7,1ry,q,kG,-774. Phone No: gas- 48-7-.7793 <br /> Contractor: A A w mg eti(r&ai an/cta Phone No: 7o7—SYs_ss z 2- <br /> License <br /> License No: gyy <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 that <br /> 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-quarters <br /> (3/4) inch in cross sectional measurement. (Use of crushed rock will <br /> not a permitted for backfill if contact will be made between the <br /> backfill material and tanks/pipes made of poly resin glass or similar <br /> materials.) <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days <br /> of project completion, or submission of verification that the select material described above <br /> will be placed at a minimum of five (5) cubic yards per 1000 gallon tank displacement and <br /> that the entire excavation will be backfilled and compacted to insure compliance with the <br /> Uniform Building Code Appendix Chapter 70. <br /> 'Name <br /> (Print) <br /> Title <br /> (Print) <br /> Signature <br /> 'Shall be the responsible managing employee on the license or authorized agent. <br />