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N TYPE: SIZE: MODEL: SERIAL NO.: EXISTING REFERENCE NO.: REPLACEMENT OLD ASSEMBLY SERIAL NO.: BACKFLOW ASSEMBLY TEST REPORT NEW PLUMBING PERMIT NO.: WATER PURVEYOR: TYPE OF SERVICE: IF APPLICABLE, WATER METER NO.: BUSINESS NAME: IRRIGATION DOMESTIC FIRE SITE PHONE: CITY: SITE ADDRESS: FACILITY MFG: ZIP: ASSEMBLY LOCATION: (Please use dimensions and references Lot Lines, Property Lines, Curb, and/or other permanent features/landmarks) OWNER / MANAGEMENT INTERNA.

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