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Certified By (Name): <br />Title: <br />Signature: <br />Date: <br />Payment <br />Date <br />Building Permit <br />Number <br />Customer Account <br />Number Property Address Size Manufacturer Model <br />Flow <br />Restrictor <br />Installed <br />(Yes/No) <br />Size Manufacturer Model Capacity <br />(gpm) <br />Fee <br />Credits <br />Applied <br />for <br />Existing <br />Meter <br />(Yes/No) <br />Size Manufacturer Model Capacity <br />(gpm) <br />Explanati <br />on for <br />Other <br />Credits <br />Fire <br />Service <br />Exemption <br />(Yes/No) <br />Amount <br />Collected <br />Amount of Fee <br />Credits (if <br />applied) <br />Amount After <br />Credits (if <br />applied) <br />1% Admin Fee <br />Retained by <br />the City <br />Total Amount <br />Remitted to <br />Zone 7 <br />Column Totals <br />1Provide a clear explanation of any fee adjustments or credits applied. If the credit is based on replacing or upsizing an existing meter, include details of the existing meter (size, manufacturer, model, and capacity) along with the new meter information reported in this form. <br />Attach supporting documentation to show how the credit was calculated (e.g., multiple meters being replaced or credits distributed across a subdivision). <br />City of Pleasanton <br />Zone 7 Water Connection Fee Reporting Summary <br />MM/DD/YYYY to MM/DD/YYYY <br />Fee Credits Information1New Flow Restrictor Information Fee InformationGeneral Information New Meter Information <br />C:\Users\bhamilto\AppData\Roaming\iManage\Work\Recent\41005.00012 Zone 7 Water Agency - vs. City of Pleasanton\Water Connection Fee Monthly Reporting Summary Sheet (long version v2)(5225250.1)Page 1 <br />Page 22 of 846