Customer Information Company Name Customer Contact Telephone Number Email Mailing Address Facility Disconnect Details Pipeline Type RECEIPT DELIVERY TransGas Meter Code Meter Name Customer Facility Location Custody Transfer Point (CTP) Location L.S.D Sect Twp Rge W Meter Station Location (If different than CTP) L.S.D Sect Twp Rge W Current Piping Configuration (at location of CTP) Above Ground Below Ground Isolation Valve Present at CTP Yes No Other Please Describe... Survey Provided of Pipeline Disconnect Site Yes No Schematic or Picture Provided for Proposed Piping Changes Yes No Customer Field Contact Name Position Telephone Number Email Customer facilities to be: Depressurized Removed and Remediated Temporarily Shut-in What length of time? Scope of Work for Disconnect (Describe the work to be completed) Expected State Date for Disconnect Work Completion Date for Isolation Attachments Include drawings or sketches to show work and indicate the distance to the TransGas facility or pipeline. One file only.10 GB limit.Allowed types: pdf, doc, docx, xls, xlsx, jpg, jpeg, png, txt, csv. Authorization By signing this document, I hereby declare myself to be a valid representative of the company noted above (The Customer) and that I am authorized to request the disconnection from the TransGas system and agree to the following terms related to the Disconnection Process. I acknowledge that any work relating to disconnecting equipment from the TransGas system is being done at the sole request of The Customer. I agree that no disconnection shall occur at the CTP without notification to and approval by TransGas. A TransGas representative shall be on-site during the disconnection unless this requirement is waived by TransGas. Upon voluntary disconnection from the TransGas system by a TransGas customer, TransGas reserves the right to abandon, recover, and/or remove any facilities at or upstream from the approved CTP at their own discretion. Any future requests to reactivate TransGas facilities at or upstream of the CTP will be completed at the customer’s expense. Name Position Date
