Address where gas is to be furnished:
Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:
Email Address :

Date Moving In:

Address to be Billed (IF DIFFERENT):

Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:

CHECK ONE OF THE FOLLOWING:

HOME OWNER   TENANT   BUSINESS

If you are a TENANT you must list Landlord's
Address and Phone Number (REQUIRED)
Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:

Please list an Emergency Contact:

Full Name (First, MI, Last):
Street Address:
City:
State:
Zip Code:
Telephone:

Before Submitting you must review "Terms and Conditions" Then type your Initials in the the box to show that you have read the terms and conditons.
(Initial Here) (REQUIRED)by initialing this box you are stating that you have read and agree to the "Terms and Conditions" set forth by Piedmont Gas Co.

The Following information is needed for NEW Service Line Installation
Service Line to be installed at Applicants Expense by:

Piedmont Gas Company     OQ Approved Contractor

 

EXCESS FLOW VALVE NOTIFICATION

Federal Regulation Number 192.383 requires that we notify you as to the availability of excess flow valves in gas service lines.

Excess flow valves which meet new federal government standards are available to be installed by Piedmont Gas Company for single new or replaced residential gas service lines, which operate continuously at or above 10 psi, at your cost.

An excess flow valve is a device designed to automatically shut off the flow of natural gas if the gas service line breaks. Potential safety benefits may be derived from installing an excess flow valve, such as less chance of personal injuries or property damage resulting from excavation-related accidents. An excess flow valve does not protect against slow leaks resulting from corrosion or threaded joints, or against leaks which develop beyond the meter assembly.

Excess flow valve installation is not mandatory. If you decide to have an excess flow valve installed on the gas service line, you must pay all costs associated with installation and any installation costs from $75.00 to $110.00. Maintenance and replacement costs can range from $350.00 to $550.00.

To obtain additional information contact:

Ohio Consumer's Counsel:
1-800-282-9448
PUCO Consumer Services:
1-800-686-7826
PUCO TTY Users
1-800-686-1570
Piedmont Gas Company
1-800-734-5724

Excess Flow Valve Installation (Read Excess Flow Valve Notification Above.)
Do you wish to have an Excess Flow Valve installed at your expense?

Yes No

Type of Dwelling

Single Family Home
Mobile Home
Business
        Space Heat Only
        Process Gas
       (If Process Gas, please describe
       in additional information box below.)
Unattached Buildings (ie. Garage, Shop, Etc.)
Other

 

Gas Equipment to be Used

                                    No. Units & BTU's

Furnace
Water Heater
Range
Dryer
Fireplace
Grill
Lights
Refrigerator
Pool Heater
Other
(List Other in box below.)

 

Use Box Below for any additional information.