Park West CC(1)-CS 960507MATERIALS ISSUED FROM SERVICE CENTER
UT~.IT~-~ DIVISION
DATE:~ ~1-~
PRO.1ECT NAME:
BrLL TO:
oo
COST OF MATF_,RIALS: $
NOTE: BEFORE FINAL INSPECTION OF THE METER & SE~I~ING CAN BE
COMPLETED, THE BACKFLOW .AEV~NTION DEVICE MUST BE
TF_~TED BY A CERTII~I'} BACKFLOW PREVENTION DEVICE
ATTACHED YES NO
DIVISION sUPERVISOR:
DISK 4 FORMS ISSUE
V~ TER UTH,ITIES DIVISION ~"
MATERIAL ISSUANCE / METER INSPECTION
Date:. ~'7- ~ G~TAG YES OR NO or
Matf~a/Issuance
Billing Address
NOT Ni~J~ED
Ptlon~.
Materials Issued: Cost ,
Meter Numb~r~ Meter Reading.
Signature of ~e p~ up m~
Meter Information:
Dat~ of Inspection,
Employ~ Maki~ Inspection:
Model:
Vault: ~ Box:.
~kflow ~e (Il' Applicable)
Vault:
Inspection Comments:
Serial Number:
Disk 4 Forms (issuance)