Central Time (CCT):
Form of Service Request

Any party requesting service, agency authorization, or pooling on Dominion Energy Carolina Gas Transmission, LLC’s ("Pipeline") system must complete this Service Request Form, either electronically on Pipeline’s Internet Website or on a paper copy. Completed Service Request Forms shall be sent to:

Customer Services Department
Dominion Energy Carolina Gas Transmission, LLC
121 Moore Hopkins Lane
Columbia, SC 29210

No request for service shall be considered until a completed Service Request Form is received by Pipeline’s Customer Services Department.

("Requesting Party") provides the following information in connection with this request:

1. Type of service or agreement (check only one):






2. Date Service or Agreement is requested to Commence/End:

 
Please enter a valid date.
 
Please enter a valid date.

3. Requesting Party (Complete Legal Name):

(a) Type of Legal Entity:

(b) State of Incorporation:

(c) D-U-N-S® Number:

(d) Requesting Party is (check only one):



4. If Requesting Party is acting as agent in arranging this service, specify below each principal (complete legal name, type of legal entity, D-U-N-S® Number, and State of incorporation) and its respective type of company(see 3(d) above). Requesting Party must supply an Agency Authorization Agreement for each principal.

5. Are additional or new facilities required to be installed or constructed by any party to implement this request? If so, please specify:

6. Name and full title of officer (or general partner) of Requesting Party who will execute service agreement with Pipeline:

7. Business contact person for this request:
Name & Title:
Mailing Address:
Phone: Facsimile:
E-mail address:

8. 24-hour contact person and phone number for dispatching gas to and from Receipt and Delivery Points:
Name & Title:
Mailing Address:
Phone: Facsimile:
E-mail address:
(specify one):

9. Person to whom invoices and billing notices are to be directed:
Name & Title:
Mailing Address:
Phone: Facsimile:
E-mail address:

10. Proposed Maximum Daily Transportation Quantity (FT) (Dts):

Proposed Maximum Daily Transportation Quantity (BH) (Dts):

Proposed Maximum Daily Transportation Quantity (IT) (Dts):

Proposed Maximum Park or Loan Quantity (PAL) (Dts):

Proposed Maximum Park or Loan Duration (PAL) (Days):

Proposed Receipt and Delivery Points:

Point NamePoint CodeReceipt/DeliveryMDRQ/MDDQ
 

11. Requesting Party certifies that Shipper has title, or current contractual right to acquire title, to any gas supply needed to implement this request, and that Shipper has entered into, or will enter into, all contractual arrangements necessary to ensure that all upstream and downstream transportation is in place prior to the requested effective date.

Printed Name:

Title:


E-mail Copy To: