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FiYDRAAT USE PIILM?T Ll��� v�rm�c no. <br />� <br />90 Day Maximuin /I �, <br />� neposic s � <br />rouurtr's 0.ecetpt Mo. � <br />���a,- JP��ain_�o�ts�rr��idn �o �{/,Ctl, <br />�PPLILANT (Princ ot Type) <br />�53- �o3a <br />lUSINESS PHOKc <br />/a p� S � � �np,u � � Gt/a y <br />IIYDRA.�T LOCATIO� <br />,�/ 7 /�' � <br />5T � DAi <br />DsDoet: Reounred: <br />Hrdnnc Valve AssrnFly Sd00 7OD� <br />HvdTant wrenth S50 5 �� <br />Macer Us� - S�i Deposf: N 7�G <br />(SIi/no oi pottton tSeteof) / <br />TOTAL DEPOSI: REOUI0.E� ( /✓ � <br />Reurca/Londl2�ons: <br />AtRN01ILEDGFY.F.F' <br />Tne unaerstpned ouneriapplfcant hereb• ■Rre<s co hold •nd <br />sare har¢less tne Qev oe Evercet from sny and all clau <br />(o� daugez, costs, e:p<nses or causes oi action t�at uy <br />■Nse beuuse ot �nstallacton and euntenance of the <br />LD�ore�ent or other ciQh[-of-vay use �ereto appl�ed and <br />fuither aRrees ro renov< sue uDa� �ot�ee from the CS[y <br />and [o renlace puAlic propercy damoyed thereby. <br />�'� %! /"��IldL -S/'S /�i� <br />S�g afure oE ADPllcont �e e <br />i55UrD BY: ,� !� � 1 ��1 / ' � 2�1 <br />DATe: � / <br />�n /lP vu�. � � y <br />l �300 -�� �l �`�.. A�e s� S�„ �� <br />ADURESS i <br />355-5/6G �;bti ,� ,, 1 <br />HORE PHONE /� <br />�1%Rs�i ,�rctc� � <br />HYDRA�T TO AE USE� FOR <br />EIPiRATfOF DATE (90 DAY M,1S.i <br />Feferences <br />Hvpnn[ Yalre Assy �o. <br />Hvdzanc \'alre Ass.• Issued Bv <br />�Onitcant's I:vdrar.t Yalve <br />Assy Inspected By <br />Ma[cr Truck inspecced On _ <br />Truck Inspected By <br />Truck Llcense Fo. <br />EC��IP11E\i RETUR!:� <br />Hvdnnc Valr_ [1n1[lal/dace) <br />Hrdran[ Mrenth (Ini[faVda[e) <br />Aeurks <br />Refund AutAori:acion <br />Amount of ReEund <br />NOT'E: <br />1. Applicant is liable £or damage - close hydrant slowly. <br />2. Refund policy -"original" treasurer's reciept re uired. <br />3. Return location - valve assembly F, wrench must�urned to Operations and riaintenance <br />Dispatcher, lst floor Service Center, 3200 Cedar Street for reEund authorization. <br />4. Failure to return hydrant valve assembly anci xrench within 90 days may result in <br />forfeiture of deposit. <br />1/86 <br />