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ELEVATED PRESSURE DELIVERY REQUEST FORM
Date:_02 April,2012
Atmos Energy Corporation
Greeley,CO 80631
Fax: 970-304-2085
Mobile: 970-567-4058
Office: 970-304-2075
Re: Request to Receive Natural Gas at an Elevated Delivery Pressure
Meter Location
Company/Business or Individual: Weld County
Contact Name: Toby Taylor Contact Phone#:_970-304-6531
Location Address: 1113 H Street CNG Facility
Town:_Greeley State: CO Zip: 80631
Commercial Yes
Customer Information for the Site
Company/Business or Individual: Weld County
Address PO Box 758 Premise Number: 2482358
Town: Greeley State: CO Zip_80631-0758
Contractor Assurance of Equipment Performance
I request that Atmos Energy provide natural gas at an elevated delivery pressure at the above described location. I understand,accept,and
acknowledge that the elevated delivery pressure may vary from 0 psig to 70 psig and that Atmos Energy is not providing a guaranteed line
pressure. Further,I understand,acknowledge,and accept any and all responsibility and liability for the use of the elevated pressure gas
delivered to the above described location. I affirm that all required pressure protection(regulators,pressure relief devices,etc.)downstream
of the receipt point(meter location)is in place and meets the pressure rating required to accept the elevated natural gas pressure requested. I
affirm that all piping and equipment within the natural gas system downstream of the receipt point(meter location)meets or exceeds and will
remain in compliance with all applicable code requirements. I affirm that all required plumbing pressure inspections will be performed
before the delivery of elevated pressure natural gas and that the requirements of NFPA 56,as applicable, will be met. Finally,I acknowledge
that I may bear responsibility for any additional costs incurred by Atmos Energy associated with the installation of the elevated pressure
construction.
Installation Contractors Signature:
Printed Name Zeit Energy
Signature
Title_VP Eng. &Ops.
Phone number 214-438-0806 Date 04/02/2012
Customer Acknowledgement Signature:
Printed Name Sean P. Conway, Chair, Board of Weld County Commissioners
Signature Title Chair d ,e5Q4
®evr
Phone number 970-336-7204 Date APR 1 6 2012 2012-0980
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