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HP HP HP HP <br />∿∿∿Map/Plat/Block:Notif. #:PM Order #:Leak #: <br />Gas Service Record (GSR) <br />If completing this form by hand, use non-erasable blue or black ink. <br />Form TD-9500P-14-F01, Rev. 2aPublication Date: 03/20/2019Effective Date: 05/20/2019 <br />Pacific Gas and <br />Electric Company® <br />Applicant/Tract Name:Date Issued: <br />Lot #:Address:City:Est. LAN ID: <br />118796156 <br />35181927 <br />2870-H5-01 <br />5166 E HARNEY LANE LODI CARL ELKINS 209-321-5462 J2MJ 06/26/2020 <br />WIRECONTACTSAs-Built By: <br />Size: <br />Type: <br />Location:Bypass: <br />Isolated Steel Service (ISS): <br />Anode: <br />Type: <br />Size: <br /># Installed: <br />Status: <br />Start: <br />End: <br />Connection Method: <br />Main: <br />Installed Stub/Service: <br />Existing Stub/Service:EFVStatus: <br />Mfg: <br />Reason None: <br />Mat'l:Flow Series: <br />Location: <br /> *If LAN ID is not available, write name and company name; include employee identifier if available. Draw sketch in space below. <br />None Existing <br />Plastic Metallic <br />Elster-Perfection Other:CURB VALVEStatus: <br />Mfg: <br />Mat'l: <br />Size: <br />None Existing InstalledPlasticMetallic <br />PIPE DEPTHNone <br />MainRiser <br />Existing <br />BranchBranch <br />Installed <br />Other:Other:Bond Strap/Wrap <br />Connection Method:Bond Strap/Wrap RISERStatus:Existing Installed in. <br />Prefabricated Service Head Adapter SteelOutsideInsideNoYes <br />No Yes Existing <br />No Existing Installed <br />Zinc Magnesium <br />lbs. <br />Riser Valve ServiceISS Weld Inspection Required: <br />By:(Qualified field rep. LAN ID and signature or printed name*)Date: <br />Type:Radiographic Visual Mag. ParticleWELD INSP.CP Read Required: <br />By:(Qualified field rep. LAN ID and signature or printed name*)Date: <br />YesNo <br />Reading Location:Riser Valve ServiceCP READSPipe-to-Soil:mV <br />(LAN ID)Contractor:(Name and company name)Date:NOTESInstalled <br />YesNo <br />1/2"Size:1"Other:1/2"1"Other: <br />400 800 Other: <br />© 2019 Pacific Gas and Electric Company. All rights reserved.PG&E Internal <br />in.in. <br />in. <br />in. <br />in. <br />Riser Valve Mfg.:Jomar <br />As-Built By:(LAN ID)Contractor:(Name and company name)Date: <br />Type:Size:Cathodic Protection LocatingSize: <br />Other: <br />X X <br />X 3/4" <br />X <br />X <br />X <br />X <br />X X <br />PG&E TO DO ALL WORK. ENCROACHMENT PERMIT NEEDED. CUT OFF EXISTING 3/4" STL HP SVC @ 3" STL HP MAIN. <br />Install Pipe: <br />By:(Person in charge LAN ID and signature or printed name*)JOB TYPETEST (1)Type: <br />Excavation Agent: <br />Installation Agent: <br />Date: <br />No Yes <br />Other:Stub <br />PG&E Applicant <br />PG&E Applicant Branch Service - Ref. #Riser <br />Full ServicePartial Service <br />Full ServiceBranch Service - Ref. # <br />StubStub Completion <br />Main ServiceINSTALL (2)Completion <br />Convert to: <br />New Service: <br />Replacement: <br />Date: <br />Pressure:Duration:min. <br />Tested by:(Qualified field rep. LAN ID and signature or printed name*) <br />psig <br />Install Pipe:No YesPE2406/2708 Other: <br />Mfg: <br />Mfg Date: <br />Other: <br />By:(Person in charge LAN ID and signature or printed name*) <br />Type: <br />Excavation Agent: <br />Installation Agent: <br />Date: <br />Other: <br />PG&E Applicant <br />PG&E Applicant <br />TEST (2)Date: <br />Tested by:(Qualified field rep. LAN ID and signature or printed name*)INSTALL (1)PIPE (1)PIPE (2)Type:PE2406/2708 Other: <br />Mfg: <br />Mfg Date: <br />Other: <br />Pressure:Duration:min.psig <br />TransferAlterationRepairDeactivationUprate <br />Other <br />Soap Test Soap Test <br />New Phased Service <br />Performance/Driscoplex Performance/Driscoplex <br />Type: <br />X CUST REQ <br />X C/O @ MAIN <br />X