Customer Consent to Remove Facilities
Customer Name: ________________________________________________________________
FID/SSN: ______________________________________________________________________
Northern Natural Gas (Company)
Location of Facilities:_____________________________________________________________
___________1/4, Section ______________, Township ______________, Range _____________
County ___________________________________, State _______________________________
Line Number _________________ Line Name _________________ Milepost ________________
As the legal owner of the above premises upon which Company’s tap is located, I hereby
authorize Company to remove its existing facilities, as I no longer desire natural gas service.
Company shall have no further responsibility for a tap at the above location. To the extent said
removed facilities were originally installed pursuant to the terms of a pipeline easement, the
removal of the facilities will discharge any further obligation of Company with regard to providing
such service upon the easement.
____________________________________
Landowner Signature
________________________________
Date
ATTACH THIS FORM TO THE RIGHT OF WAY GRANTOR FARM TAP REQUEST
INTERNAL USE ONLY
____________________________________
Owner Company Representative
____________________________
Date
____________________________________
Team Name
____________________________
Phone Number
If known, please provide the following information:
Date of original installation
________________________________
Landowner in whose name the original installation
was granted
________________________________
Original FERC authority to install
________________________________
customer_consent_to_remove_facilities_5057Q_102408.doc
Docket No.
Form 5057Q, Rev. 2, 10/24/2008