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City of
�t Collins
Community Development & Neighborhood Services
281 N College Ave; P.O. Box 580; Fort Collins, CO 80522-0580
Phone: 970 221 6760 FAX: 970 224 6134
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v- 'ield Verification Form
Job Site Per o—�e y�q
Company Name ts1OCn MAu-W"VO c nA City of Ft Collins Lic# - ' !"I
Replacement of Sewer line
Replacement of Water line
Add Replace gas line
approx. ft. (100 ft. maximum)
approx. ft. (100 ft. maximum)
approx. -11:�C ft. (50 ft. maximum)
Materials used: Me, 1C.SS"C
Tested at
Lbs. for Q.-1f\r, ruRrIas
Installer Name (print) Oita, `..C\-LLLr—
Installer Signature 0 1 ti Date 10 -2L-