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Rev. 3 Pacific Gas and Gas Service Record (GSR) omT°-tionData09,,/204 Publication Date: Electric Company 12/01/2024 If completing this form by hand, use non —erasable blue or black ink. Effective Dale: 12/01/2024 Lot #: Neff. #: 131532922 PM Order #: 35735652 Leak #: Address: 3040 W BEN HOLT DR City: STOCKTON Applicant/Tract Name: Est. LAN ID: EAMC Date Issued: 5 19 2026 Install Pipe: ❑ No ❑ Yes Install Pipe: ❑ No ❑ Yes ❑ New Phased Service W Type: ❑ HE 2708 ❑ Other: w Type: ❑ PE 2708 ❑ Other: L-1 Stub ❑ Stub Completion a Mfg: a Mfg: New Service: Mfg Date: Mfg Date: ❑ Full Service [-]Branch Service - Ref. # Replacement: Type: ❑Stub ®Other: FULL SERVICE REPLACEMENT Type: ❑Completion ®Other: ABANDONMENT Excavation Agent: ®PG&E ❑ Applicant cr Excavation Agent: ® PG&E ❑ Applicant w ® Full Service Installation Agent: ® PG&E ❑ Applicant Installation Agent: ® PG&E ❑ Applicant ❑ Partial Service N B , y B y m o ❑ Branch Service - Ref. # 6608 z (Person in charge LAN ID and signature or printed name') Date: z Person in charge LAN ID and signature or printed name') Date: ❑ Riser ❑ Transfer ❑ Alteration ❑Repair ❑ Soap Test ❑ Verified plastic pipe surface temp. per TD-4138P-01 ❑ Soap Test ❑ Verified plastic e surface temp. per TD-4138P-01 P PP P P IS Tested by: S Tested by: El Abandonment (Qualified field rep. LAN ID and signature or punted name') Date: Qualified field rep. LAN ID and signature or printed name+) Date: ❑ Uprate Convert to: ❑ Main ❑ Service Pressure: psig Duration: min. Pressure: psig Duration: min. El Other: x Main: in. Status: ❑None ❑Existing ❑Installed Status: ❑None ❑Existing ❑Installed Installed Stub/Service:—In. cReason None: Flow Series: 1800 Mat'I: ®Plastic ❑Metallic Mfg: a Mat'I: ®Plastic ❑Metallic Size: ❑y in. ®1 in. ❑Other: in. m Size: ❑y in. ®1 in. ❑Other: in. a Existing Stub/Service: in. Mfg: 6 Critical Isolation Valve: ®No ❑Yes ❑Unknown Status: ❑None ❑Existing ❑Installed Status: ❑Existing ❑Installed ❑Removed Size: 3/4" 1" in. Type: ❑ Cathodic Protection Size: ® Locating Size: #14 ,�, Location: ® Outside ❑ Inside Bypass: ❑ No ® Yes 3 Start: ®Main ❑Branch ❑Other: Connection Method: ®Bond ❑Strap/Wrap s Type: ®Prefabricated ❑Service Head Adapter ❑Steel End: ®Riser ❑Branch ❑Other: Connection Method: ❑Bond ®Strap/Wrap Riser Valve Mfg.: ❑domar ❑Other: Isolated Steel Service (ISS): ® No ❑ Yes ❑ Existing N CP Read Required: ®No ❑ Yes Weld Inspection Required: ❑ No ® Yes Anode: ® No ❑ Existing ❑ Installed Size: lbs. By: z By: (Qualified field rep. LAN ID and signature or printed name') (Qualified field rep. LAN ID and signature or printed name') i — Type: El Zinc El Magnesium # Installed: Pipe -to -Soil: mV Date: Date: Location: ❑Riser ❑Valve ❑Service Reading Location: ❑Riser El Valve El Service Type: El Radiographic ❑ Visas l ❑Mag. Particle As-Built By: (LAN ID' Date: z � LANIDs' of Qualified field representatives who made the following connections: Fusion: o As -Built By: Date: =Mechanical: g (LAN ID*) Weld: 1. EFV SIZED PER A-93.3 REV 10 BASED ON METER CAPACITY OF 735SCFH FOR 1-275 AND 1-250 METERS. 0 2. DEPTH OF EXISTING SERVICE UNAVAILABLE AT TIME OF DESIGN. IF DEPTH IS FOUND TO BE NOT COMPLIANT WITH A-04, INSTALL A 1" PL SERVICE WITH A 1" PL 1800 EFV. Z 3. MAY USE EXISTING TEE IF 3/4" STL OR LARGER. *If LAN ID is not available, write Industrial Training Services [ITS] ID or Stencil ID. For non -qualified tasks only: If ITS ID or Stencil ID is not available write name and company name; include employee ID if available. Draw sketch in space below. P/L W BEN HOLT DR (84') P/L 0 124' � r€MI cn ° Do N 2 ABDN. 1-1/4" } CD ;pp11____ STL — 1969+ INST. 1" PIL 1„ } €M1 IN 1 " PL t N M 1 1 /4" STL N ELBOW I —14' VALVE INSERT 122' Ell 3—WAY 11 ~INST. 1 " PL N TEE I (INSERT) I. r— U, I 4- 50' w I V) N zl ¢N SHED w i ABDN. 1/2" PL — 1978 1" 6 + ELBOW ---IN] ------------ __ 7' — 1. (TRENCH)---T---+- ELBOW INST. 1" PL ELBOW 6608 41' n Z PG&E Internal 02024 Pacific Gas and Electric Company. All rights reserved.