Permits & Development - Encroachment(EP)/Driveway(DW) Permits - 2019_PS-1903501 thru PS-1904000_ - PS-1903849

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Pacific Gas and Gas Service Record (GSR) FOrmTcation Electric Company p y • Publication Date: 03/20/2019 ate: 3/20/2019 If completing form by hand, use non -erasable blue or Ink. Effective Date: 05/20/2019 Map/Plat/Block: 2947-C3-04 Lot M Notif. #: 117938742 Address: 11190 N GOLFVIEW RD. City: LODI PM Order #: 35135845 Applicant/Tract Name: SHERRY LEE 209-481-5067 Est. LAN ID: 12M1 Date Issued: 11/14/2019 Leak #: Install Pipe: ❑No❑Yes Install Pipe: ❑No❑Yes ❑ New Phased Service Type: ❑PE2406/2708 ❑Other: Performance/ Mfg: ❑Driscoplex ❑Other: N a s Type: ❑PE2406/2708 ❑Other: Performance/ Mfg: ❑Driscoplex []Other, El Stub ❑StubCompletion New Service: E eW. a Mfg Date: Mfg Date: ❑ Full Service [I Branch Service - Ref. # Type: []Stub []Other: Type: (I Completion ®Other: CUT OFF @MAIN Replacement: Excavation Agent: ❑PG&E []Applicant Excava:ionAgent: ®PG&E []Applicant o ❑Full Service a Installation Agent: []PG&E❑Applicant a Installation Agent: []PG&E Applicant El Partial Service N m ❑Branch Service -Ref. # z — By: z — By: o El Riser ❑ (Person in charge LAN ID and signature or printed name'( (Person in charge LAN ID and signature or printed name' Date: Date: Trarsfer ❑ Alteration []Soap Test ❑ Soap Test ❑ Repa'r Tested by:Tested 'printed by: [X]Deactivation CUSTOMER REQUEST s'_. (Qualified field rep. LAN ID and signature or i-— (Qualified field rep. LAN ID and signature or printed name') ❑ Uprate Date: Date:.Convertto: ❑Main❑Service Pressure: psig Duration: min. Pressure: psig Duration: min. ❑Other Main: in. Status:®None❑Existing[Installed Reason None: I W Status, ®None❑Existing ❑Installed wMat'I:❑Plastic❑Metallic Flow Series: ❑400❑800❑Other: Mat'I;❑Plastic ❑Metallic o Installed stub/Service: in. a Slze:❑ 1/2"131" El Other: ln. Size:❑1/2"❑1" ❑Other:In. a Existing Stub/Service: In. Mfg: ❑Elster-Perfection ❑Other: v Mfg: Status: ®None❑Existing El Installed Status: ®Existing ❑Installed Size: 3/41t in. Type:❑Cathodic Protection Size: []Locating Size: W Location: ® Outside ❑Inside Bypass:®No❑Yes 3 Start: ❑ Main ❑ Branch ❑Other: Connection Method:❑Bond ❑Strap/Wrap Type: ❑Prefabricated ❑ Service Head Adapter ®Steel End: ❑Riser ❑Branch ❑Other: Connection Method:❑Bond ❑Strap/Wrap Riser Valve Mfg.: ❑iomar❑other: Isolated Steel Service (ISS): ® No ❑ Yes []Existing CP Read Required: ®No El Yes Weld Inspection Required: 0 N ®Yes Anode:®No❑Existing❑Installed Size: Ibs,W h By: a By: am? (Qualified field rep. LAN ID and signature or printed ne') in (Quahfled field rep. LAN 10 and signature or printed name') — Type: ❑ Zinc ❑Magnesium # Installed: z Pipe -lo -Soil: mV Date: W Date: Location: ❑Riser []Valve []Service Reading Location: ❑Riser []Valve ❑Service �' Type:❑Radiographic ❑Visual ❑Mag. Particle L^, As -Built By: Contractor: Date: F (LAN ID) (Name and company name) o As -Built By: Contractor: Date: (LAN ID) (Name and company name) ,in PG&E TO DO ALL WORK, ENCROACHMENT PERMIT NEEDED. CUT OFF EXISTING 3/4" HP STLSERVICE @ 2" STL MAIN. {D 0 z 'If LAN ID is not available, write name and company name; include employee Identifier If available. Draw sketch In space below. � DEACTIVATION a a PM: 35135845 NOBF: 11793B742 DALE w WX BY SKYIATURE LAN 16 EXCAVATED BY: ❑ PG&E ❑ IHHER ft 1 1 190 15r Cur OFF LOCATION: ❑ MWN ❑ PA ❑ TPD LINED LOC, L0 N GOLFVIEW RD, EM BNL Ilii 111D". ❑ YES ❑ NO (SEE SKETCH) GSR# DEAL PPE SEAIEO PER TOm%OOP-lP: ❑ 1ES ❑ NO 3/4" STL 5603 2ND CIT OFF LOCATION: ❑ RISER ❑ RED LINED LOC. (SEE SIM) M C I r + DEC PPE Sfi4EO PER TD -9500P-16^ ❑ YES ❑ NO 0 117' TOTAL LENGTH CUT OFF: PIPE SIZE EM PIPE TYPE EI PL ❑ SR ❑ W W YEAR DEAL. PPE MST: — > WELD ISPECIED BY: 0)J CAP NSfPllID BY: 0 w CAP NST, YERIAM E4: CD SOAP TESTED BY: WAS REMIND. ❑ YES ❑ NO z K1EMy 011 sinal AW AM MM 0 110" Da f2P5, DC FOR AL SERVICE DEACTIVATIONS, DOCUMENT END CAP HAD BEEN INSTALLED. N I PERFORMER: VERIFIER: J t- tn n 2 N P/L ~ P/L N P/L P/L 8 MILE RD. PG&E Internal 0 2019 Pacific Gas and Electric Company. All rights reserved.