PIPELINE OCCUPANCY APPLICATION

(NCRR FORM 220)

This form is to be used when submitting a utility occupancy application for an underground pipeline.Use NCRR Form 2010 for wire ,conduit or cable occupancy applications

Submit a cover letter,including a project description ,and the completed application,application fee and (1) copy of the project plan to:

HNTB North carolina ,p.c
Attn: Manager,NCRR Pipes and Wires
Occupany Agreement Process
343 E.six fork Rd,suite 200
Raleigh ,North Carolina 27609

FOR NCRR/HNTB use only

FILE NO:

NCRR ID#:

Plans for proposed installations are to be submitted to, and shallmeet the approval of ,North Carolina Railroad Company (NCR). Applicant shall enterinto an occupancy agreement with NCRR before any construction activities commence on site .materials and installation are to be in strict accordance with specification of the American Railway Engineering and maintenance -of-way Association (AREMA),North Carolina Railroad company, and the operating railroad(Norfolk Southern Corporation and/or CSK Transporation as appropriate). The information submitted with this signed application and the required number of copies shall be per the Pipeline and Underground/Aerial Occupancy Application instruction (NCRR Form 230) The engineering application fees to be submitted with this application are as started in current engineering fee sechedule(HN-02)

PROJECT OWNER/APPLICANT INFORMATION

1. Owner Legal Name

*please Ensure that the exactlegal name is provided with no Abbreviation.

2. Owner Street Address Name

city:

state:

zip:

3. Owner Mailing Adress (if different):

Street Address\P.O Box:

city:

state:

zip:

4. Name of owner's Representative:

Title:

Street Address:

city:

state:

zip:

Email:

Telephone Number:

Ext:

5. Name of owner's Contact for Billing purposes:

Title:

Street Address:

city:

state:

zip:

Email:

Telephone Number:

Ext:

6. Billing: Owner prefers

yearly or

one time non assignable payment of occupany fees

7. Owner is A:

Corporation-State of formation:

Limited Partnership-State of formation:

Limited Liability Company-State of formation :

Generel Partnership-State of formation:

Sole proprietorship-State of formation:

indivisual-State of formation:

Government Entity-State of formation:

Other-State of formation:

Name and Adress of the owner's engineer or consultant (i.e the party that will be coordinate the project -leave blank if none or same as applicant.)

8. Company Name:

9. Contact Person Name:

Title:

Street Address:

city:

state:

zip:

Email:

Telephone Number:

Ext:

PROJECT INFORMATION

10. proposed work involves (check all that apply)

Existing Agreement of installation?

installation of new facility

Revision to existing facility

Upgrade to existing facility

yes

Unknown

*please include with the application a copy of the existing agreement between the applicant and North Carolina Railroad and /or Norfolk Southern Railway(or prdecessor)

11. Location of installation:

Nearest Street:

Nearest Town:

Country:

State:

Latitude

Longitude

12. Railroad Milepost Reference*:

Feet

*use the next lowest whole milestone adjacent to the project location + feet in the direction of increasing milestone to the project location .Applies to all milepost references in the application.

Mainline-increasing milepost from Goldboro (MP 284) to Charlotte (MP 375)

H-line incresing milepost from Goldboro (MP H-0) to Goldboro(MP H-130)

EC-line-increasing milepost from Goldboro (MP EC-0) to Morehead City (MP EC-94)

13. Oriented of proposed pipeline installation:

Transverse crossing only -fill in #14 below

Longitudinal (parallel to track) only-fill in #15 below

Longitudinal and transeverse crossing-fill in #16 below

14. For a transeverse crossing under the track:

Number of track to be crossed:

Angle of crossing:

Total lenght of crossing on the NCRR Corridor: