Form for New and Existing Interconnects

Interconnect Request Form

Required Fields are marked with an asterisk (*).

Request Type *

Meter Owner Information

Company Name *

Contact(s) *

Address *

Street, City, State, Zip

Phone *

(999-999-9999)

Fax *

(999-999-9999)

Email Address *

Proposed Meter Site Information

Meter will be sized accordingly to volume specified. If volume changes and is significantly different than request, meter owner will be charged additional fee for appropriate sizing.

Meter Number *

Site Name *

Interconnect Type *

Current Max Volume *

(Mcf/D)

Future Max Volume *

(Mcf/D)

Current Pressure *

(psig)

Current MAOP *

(psig)

Estimated New Pressure *

(psig)

Anticipated Initial Volumes *

(Mcf/D)

Future Expansion Expected

Yes No

Future Volume Expected *

(Mcf/D)

Estimated Min Pressure *

(psig)

Estimated Normal Pressure *

(psig)

Estimated MAOP *

(psig)

Gas Quality *

Shale Formation *

State *

County *

Township *

EQM Pipeline #(s)

GPS Location (latitude) *

(ex: 39.12345)

GPS Location (longitude) *

(ex: -80.12345)

Requested Turn-in-Line Date *

(mm/dd/yyyy)

Additional Pertinent Information

Attach Topographic Map