DOMINION SOUTH PIPELINE COMPANY, LP
SEND TO: Dominion South Pipeline Company, LP
120 Tredegar St., Richmond, VA 23219
P.O. Box 26532,
Richmond, VA 23261
Attn : Terry Cole
Phone : (804) 819-2862
FAX : (804) 819-2065
1.
Type of Request (please check the appropriate line):
____ NEW SERVICE. If checked, please provide all information
requested on the attached pages. Requests will be considered
invalid unless all information is provided.
2.
Shipper Information:
Shipper name: ______________________________________
State of Incorporation: ______________________________________
Name and title of person executing Transportation Agreement:
__________________________________________
Shipper is (check one):
___ LDC ___ End User ___ Marketer
___ Interstate ___ Intrastate ___ Producer
___ Broker ___ Other
3.
Requesting Party Information (if different
from 2.):
Name:
______________________________________
Contact person: ______________________________________
Phone: ______________________________________
Notices
Address:
Name:
______________________________________
Address: ______________________________________
Attn: ______________________________________
Phone: ______________________________________
Invoices Address:
Name:
______________________________________
Address: ______________________________________
Attn: ______________________________________
Phone: ______________________________________
Contracts Address:
Name:
______________________________________
Address: ______________________________________
Attn: ______________________________________
Phone: ______________________________________
4.
Intended Use of Gas:
___ System Supply ___ End use by industry ___ Other
5.
Regulatory Authority:
Please designate the applicable transportation regulatory authority for the requested service (check one).
_____ Subpart B of Part 284 (i.e., Section 311) transportation on behalf of local distribution company or intrastate pipeline. NOTE: under Section 311 authority, the requestor represents that the local distribution company or intrastate pipeline on whose behalf transportation service is requested either
a. has physical custody of and transports the gas at some point
in the transaction, or
b. has title to such gas at some point in the transaction for a purpose related to its status as a local distribution company or intrastate pipeline.
_____Subpart G of Part 284 (i.e., Order 500, Section 284.222) transportation by an interstate pipeline for interstate pipeline.
_____Subpart G of Part 284 (i.e., Order 500, Section 284.223) transportation by an interstate pipeline for any other shipper.
_____ Section 7 (requires FERC order approving request of certificate filing).
6. If specific activities will be performed by Shipper’s Agent, a copy of the Customer Designation of Agent (CDA) which can be found on Dominion South Forms website must be attached and this section must be complete.
Agent functions will be performed: _____ Yes _____ No
CDA attached: _____ Yes _____ No
7. Contract Term: Commencement date: _______________________
Termination date: _______________________
8. Type of service (check one):
_____ Firm _____ Interruptible
9. Contract quantity (in dekatherms):
Maximum daily contract quantity:
________________________
Maximum annual contract quantity (FT only): ________________________
Total contract volume (life of
contract):
________________________
10. Please check either Master Meter Receipt Point List or specific receipt point(s):
_____ Master Meter Receipt Point List OR _____ Specific Receipt Point(s)
If you are requesting specific receipt points, please identify the interstate pipeline, intrastate pipeline, or local distribution company which will deliver the gas to Dominion:
________________________________________________________________
________________________________________________________________
11. Please identify, with specificity, each point at which gas is to be received by Dominion (to be completed only when requesting firm transportation):
________________________________________________________________
________________________________________________________________
Points of
Delivery
12. Please check either Master Meter Delivery Point List or specify delivery point(s):
_____ Master Meter Receipt Point List OR _____ Specific Delivery Point(s)
If you are requesting specific delivery points, please identify the interstate pipeline, intrastate pipeline, or local distribution company which will receive gas from Dominion:
________________________________________________________________
________________________________________________________________
13. Please identify, with specificity, each point to which gas is to be delivered by Dominion (to be completed only when requesting firm transportation):
________________________________________________________________
________________________________________________________________
Other Required Information
14. By signing this statement in the space which follows, the requesting party represents (i) that the Shipper or its principal will at the time of receipt have good and merchantable title to, or good right to tender, the gas requested to be transported herein, (ii) that all necessary upstream and downstream transport arrangements have been completed or will be completed prior to commencement of service, and (iii) a sales contract has or will be entered into by the party ultimately receiving the gas to be transported prior to commencement of service.
Requesting party’s signature: ________________________________________
Title: ____________________________________________________________
15. Producing area of source of gas: ______________________________________
________________________________________________________________
16. State of ultimate end use of gas: ______________________________________
17. Is requestor an energy/marketing affiliate of Dominion? ____ Yes ____ No