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Paciric Gas and Field Paving Form <br />Electric Company' <br />Asphalt <br />Mill & Fill <br />Asphalt I Concrete Combo <br />Grind <br />Asphalt Fabric <br />Asphalt Berm /Curb <br />Saw Cut <br />Asphalt <br />Concrete <br />Seal <br />Slurry / Fog I Sand <br />Striping <br />Paint <br />Thermoplastic <br />Traffic Legend <br />Double Center Lane <br />3M "Scotch Lane" <br />inches <br />Inches <br />over <br />inches <br />Depth <br />Street Address: <br />Cross Street: <br />5); <br />ity ounty: _ <br />Permit Number <br />Permit Expiration Date: <br />Color: Y I N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Color Y N Aggregate: Y I N Decorative/Stamped: Y I N <br />Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Adjust/Replace <br />Manhole Frame ea <br />Sidewalk Gas Valve Boxea <br />Secondary Electrical BoxHea <br />ea 13" x 24" 17" x 30" J 24" x 36" <br />Valve Frame as 15" 123" <br />Valve Cover 30" x 30" 32" x 32" J 48" x 48" <br />Other <br />WxL <br />F"IIf <br />If <br />W x L <br />— inches <br />inches <br />Place Paver l Stone / Brick <br />Traffic Marker Dots <br />Plug 1 I/? Gas Prospect Hole <br />Date: <br />ea <br />�.y�t <br />Foreman Name: / � I � <br />Situ, E <br />PM Number: �N 31613) <br />T <br />Concrete W x L <br />Depth <br />.Roadway <br />_ inches <br />Sidewalk <br />_ inches <br />Sidewalk <br />_ inches <br />Driveway <br />_ inches. <br />Driveway <br />_ Inches <br />Curb Ramp <br />Domes: Y / N <br />Curb <br />If Gutter: Y I N <br />Valley Gutter <br />r_1 <br />If <br />Dowels <br />ea Size: #4145 <br />Asphalt W x L <br />Depth <br />Asphalt <br />Mill & Fill <br />Asphalt I Concrete Combo <br />Grind <br />Asphalt Fabric <br />Asphalt Berm /Curb <br />Saw Cut <br />Asphalt <br />Concrete <br />Seal <br />Slurry / Fog I Sand <br />Striping <br />Paint <br />Thermoplastic <br />Traffic Legend <br />Double Center Lane <br />3M "Scotch Lane" <br />inches <br />Inches <br />over <br />inches <br />Depth <br />Street Address: <br />Cross Street: <br />5); <br />ity ounty: _ <br />Permit Number <br />Permit Expiration Date: <br />Color: Y I N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Color Y N Aggregate: Y I N Decorative/Stamped: Y I N <br />Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Color: Y/ N Aggregate: Y/ N Decorative/Stamped: Y I N <br />Adjust/Replace <br />Manhole Frame ea <br />Sidewalk Gas Valve Boxea <br />Secondary Electrical BoxHea <br />ea 13" x 24" 17" x 30" J 24" x 36" <br />Valve Frame as 15" 123" <br />Valve Cover 30" x 30" 32" x 32" J 48" x 48" <br />Other <br />WxL <br />F"IIf <br />If <br />W x L <br />— inches <br />inches <br />Place Paver l Stone / Brick <br />Traffic Marker Dots <br />Plug 1 I/? Gas Prospect Hole <br />ea <br />In Concrete: Y IN <br />Reflective: Y I N <br />Concrete I Asphalt <br />Hea <br />m <br />Width <br />If <br />If <br />ea <br />If <br />If <br />_ inches <br />inches <br />4" 8" 112" Crosswalk <br />Notes <br />