Buried and/or Aerial Crossing Information Form

1. Name of Licensee (required)
   

   Exact name of owner of utility.

2. Address of Licensee (required)
   

   Email of Licensee (required)
   

   Phone of Licensee (required)
   

   Fax of Licensee
   

3. Number of Tracks to be Crossed (required)
   

   Angle of Crossing To Track (required)
   

4. Will This Line Run Parallel To Track (required)
   YesNo

   If so, how far?
   

5. Will this crossing be located within a dedicated public street? (required)
   YesNo

   If yes, please indicate the name or number of the street
   

   Do you have the authority to acquire by condemnation?
   YesNo

   If yes, we need a letter from you stating that if you are unsuccessful in getting an agreement for this crossing, you will initiate condemnation proceedings.

6. Product to be transported
   

7. Type of Crossing (required)
   —Please choose an option—DistributionTransmissionServiceFiber Optics Line

8. Will a contractor install this crossing? (required)
   YesNo

   If yes, name and address of the contractor:
   
   

9. How many feet and direction from nearest switch, miles post marker, road crossing, or Railroad bridge? (required)
   —Please choose an option—SwitchMiles Post MarkerRoad CrossingRR Bridge

   Select one and indicate number found on structure.

   Number found on structure
   

   Section:
   

   Township:
   

   Range:
   

   Other identifying description:
   

10. Pipe Specifications

    	Carrier	Casing
    Inside Diameter	Carrier Inside Diameter	Casing Inside Diameter
    Mill Pressure CSI	Carrier Mill Pressure CSI	Casing Mill Pressure CSI
    Wall Thickness	Carrier Wall Thickness	Casing Wall Thickness
    Type of Seam	Carrier Type of Seam	Casing Type of Seam
    Laying Lengths	Carrier Laying Lengths	Casing Laying Lengths
    Kind of Joints	Carrier Kind of Joints	Casing Kind of Joints
    Total Length on Railroad Right-of-Way	Carrier Total Length on Railroad Right-of-Way	Casing Total Length on Railroad Right-of-Way

    Method of installing pipe:
    

    Vents:
    

    Size:
    

    Height above ground:
    

    Seals - Both Ends:
    

    Seals - One End:
    

    Base of rail to top of casing:
    

    Cathodic protection
    YesNo

    Protective coating
    YesNo

    Protective coating kind
    

    Type, size and spacing of insulators and supports
    

    Maximum working pressure
    

    PSI Field Test pressure
    

    PSI Type
    

    Location of shut-off valves
    

    Distance from hole to centerline of nearest track
    

    Undertrack crossings to be constructed in accordance with current specifications as designed by the American Railway Engineers Association (AREA).

11. Aerial Crossing Specifications

    Height above top of rail
    

    Poles to be located on property
    

    Voltage
    

    Attach to existing poles?
    YesNo

    If yes, give name and agreement number
    

    You will need to provide a copy of permission to attach to poles belonging to an entity other than yourself.

    Aerial crossing to be constructed in accordance with current specifications as designated by the Joint Engineering Committee of the Association of American Railroads (RRA) and the Edison Electric Institute (EEI), and, the specifications of the National Electrical Safety Code (NESC), Part 2, Safety Rules for the Installation and Maintenance of Electric Supply and Communication Lines.

12. Date you propose to make this crossing:
    

    You will need to provide Cross Sectional and Topographical Drawings at proposed crossing location showing: track, pipe, ditches, slope from property line to property line, vent locations, conduit, depth of pipe or clearance above top of rail, distance from nearest Railroad structure.

By signing this Application, I acknowledge that I have examined and will conform to the specifications as designated by the AREA, AAR, EEI, or NESC, whichever is applicable.

Please Enter Your Name as Signature

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