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MINNESOTA GAS CO. MAINTENANCE <br />❑ MAIN 0 SERVICE PAV. CUT NO. <br />` DATE 1 _( R_ 7q MUNIC. n r n n n RESP. ACCT. NO. <br />G FPC • or . E NO. <br />ORDER NO. R 7n 3 <br />LEAK RPT. NO. <br />R1 <br />LOCATION: l h -O R R a l d u r P n r k R a d <br />� NATURE OF WORK r it l. t M 1 n <br />FOREIGN STRUCTURES <br />Tele <br />I Elec <br />E Light/Traf. Cable <br />f Other <br />PRESS. CL. <br />NEW <br />❑ t <br />❑ <br />A <br />TAP <br />❑ 2 <br />❑ <br />C <br />SIZE <br />❑5 <br />❑ <br />E <br />❑ G <br />❑ <br />F <br />0 <br />❑ <br />K <br />SURFACE DISTURBED <br />❑ Road Mix Bituminous <br />❑ Hot Mix Bituminous <br />❑ Portland Cement Concrete <br />❑ Dirt <br />❑ Gravel <br />❑ oiled Earth <br />❑ Roadway ❑ Blvd. ❑ Walk ❑ Alley <br />Size Disturbed <br />PIPE LENGTH CO Same Ft. Longer Ft. Shorter Ft. Abandoned <br />SERVICE TAP MEASUREMENT <br />DATE STARTED COMPLETED�+ ., �FOREMAN, P,"�„1 <br />TOWN NO. FOREMANS P.R. NO <br />To the (City Engineer <br />(City Council <br />(Village Council <br />(Town Board <br />The undersigned hereby requests permission to perform the work <br />indicated above. <br />MINNESOTA GA COMPANY <br />By ' <br />/J: (Authorized Signature) <br />To the Minnesota Gai Company <br />Permission is hereby granted the Minnesota Gas Company to perform <br />the work indicated above. <br />t of <br />Date . , -. -� — "I By <br />(Authorized Signature) ! <br />FORM 45A R3/78 <br />