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HP HP HP∿∿Map/Plat/Block:Notif. #:PM Order #:Leak #:Gas Service Record (GSR)If completing this form by hand, use non-erasable blue or black ink.Form TD-9500P-14-F01, Rev. 2aPublication Date: 03/20/2019Effective Date: 05/20/2019Pacific Gas andElectric Company®Applicant/Tract Name:Date Issued:Lot #:Address:City:Est. LAN ID:118954304351745193005-H5-131851 E. 11TH ST. STOCKTONMELISSA NISSIM 209-468-3455 J2MJ 04/29/2020WIRECONTACTSAs-Built By:Size:Type:Location:Bypass:Isolated Steel Service (ISS):Anode:Type:Size:# Installed:Status:Start:End:Connection Method:Main:Installed Stub/Service:Existing Stub/Service:EFVStatus:Mfg:Reason None:Mat'l:Flow Series:Location: <br /> *If LAN ID is not available, write name and company name; include employee identifier if available. <br /> Draw sketch in space below. <br />None ExistingPlasticMetallicElster-Perfection Other:CURB VALVEStatus:Mfg:Mat'l:Size:None Existing InstalledPlasticMetallicPIPE DEPTHNoneMainRiser ExistingBranchBranch InstalledOther:Other:Bond Strap/WrapConnection Method:Bond Strap/Wrap RISERStatus:Existing Installed in.Prefabricated Service Head Adapter SteelOutsideInsideNoYesNoYesExistingNoExistingInstalledZincMagnesiumlbs.Riser Valve ServiceISS Weld Inspection Required:By:(Qualified field rep. LAN ID and signature or printed name*)Date:Type:Radiographic Visual Mag. ParticleWELD INSP.CP Read Required:By:(Qualified field rep. LAN ID and signature or printed name*)Date:YesNoReading Location:Riser Valve ServiceCP READSPipe-to-Soil:mV(LAN ID)Contractor:(Name and company name)Date:NOTESInstalled YesNo1/2"Size:1"Other:1/2"1"Other:400 800 Other: <br />© 2019 Pacific Gas and Electric Company. All rights reserved.PG&E Internal <br />in.in.in.in.in.Riser Valve Mfg.:JomarAs-Built By:(LAN ID)Contractor:(Name and company name)Date:Type:Size:Cathodic Protection LocatingSize:Other:X XXX 3/4"X XXXXXPG&E TO DO ALL WORK. ENCROACHMENT PERMIT NEEDED. CUT OFF EXISTING 3/4" STL HP SVC @ 2" STL HP MAIN.Install Pipe:By:(Person in charge LAN ID and signature or printed name*)JOB TYPETEST (1)Type:Excavation Agent:Installation Agent:Date:No YesOther:Stub PG&E ApplicantPG&E Applicant Branch Service - Ref. #RiserFull ServicePartial ServiceFull ServiceBranch Service - Ref. #StubStub CompletionMainServiceINSTALL (2)Completion Convert to:New Service:Replacement:Date:Pressure:Duration:min.Tested by:(Qualified field rep. LAN ID and signature or printed name*)psig Install Pipe:No YesPE2406/2708 Other:Mfg:Mfg Date:Other:By:(Person in charge LAN ID and signature or printed name*)Type:Excavation Agent:Installation Agent:Date:Other:PG&E ApplicantPG&E ApplicantTEST (2)Date:Tested by:(Qualified field rep. LAN ID and signature or printed name*)INSTALL (1)PIPE (1)PIPE (2)Type:PE2406/2708 Other:Mfg:Mfg Date:Other:Pressure:Duration:min.psig TransferAlterationRepairDeactivationUprateOtherSoap Test Soap Test New Phased ServicePerformance/Driscoplex Performance/DriscoplexType:X CUST REQXC/O @ MAINX