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SANJ U I Environmental Health Department <br /> C U I`, T <br /> BACKFILL EXCAVATION CERTIFICATE <br /> Project Location : 7� J? 7l/,/Y[- `�� � d f /� <br /> Owner f/ l Phone No : CC* <br /> Contractor:. : <br /> Contractor: :J/ /�1 ���✓Z/�� e14 14 Phone No : 7o � �Z�j <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 gravek- smooth , rounded material not more than one-half ( 1 /2 ) <br /> inch in diameter <br /> 4138 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 ZV!±1e //d2 <br /> nn <br /> Title /i4 C 7R/L <br /> Signature <br /> * Shall be the responsible managing employee on the license or authorized agent . <br /> 10 of 10 <br />