Instructions: Complete one application form for each 1/4 section of land affected. Please include drawings of your proposed work relative to the MIPL pipeline right-of-way with your application. Drawings of your entire project are not required. Note: required fields are indicated with an asterisk (*) Requestor Enter the information of the party you want the Agreements and/or replies to be sent. Company First Name Last Name Email Phone Requestor Reference #? Grantee/Owner Enter the individual or legal company name for whom the work is being completed. This will be used as the counter party for any Contracts/Agreements with MIPL and also for future legal notices for the life of any assets covered by the Agreements, not just for initial installation. Legal Company Name Grantee Signer Mailing Address City Province Postal Code Email Phone Grantee Field Contact Enter the information of the Field Contact you want MIPL to notify in future years when entering the joint crossing area covered by any Agreements issued. This information is not required for Seismic Notices. Is the Field Contact same as the Grantee Signer? Yes No Company Name Email Phone Land Location A record of locate and/or drawing is required to validate the location of where the work is taking place. Ensure it is included in your project plan attachment(s) before submitting the form.Enter the legal land location of the work you are proposing. Note: one application required per 1/4 section or land parcel affected. LSD or Quarter Section Township Range Meridian Lot Block Plan Latitude Longitude Activities Planned Select all that apply. Fencing Fence Type SelectWood PostSteel PostOther Offset from Pipeline (M)? Additional fence information Ground Disturbance? Buried Cable Crossing Buried Cable Crossing Composite Buried Cable Crossing Composite Type of Cable Type of Cable - Select -TelephonePowerFiber OpticOther… Enter other… Cable Direction Paralleling Crossing Number of Cables Voltage of Cable(s) Above Ground Cable Crossing Above Ground Cable Crossing Composite Above Ground Cable Crossing Composite Type of Cable Type of Cable - Select -TelephonePowerFiber OpticOther… Enter other… Cable Direction Paralleling Crossing Number of Cables Voltage of Cable(s) Is your work within 30 metres of a MIPL cathodic facility (ie. rectifier or ground bed)? SelectYesNoUnsure Culvert Diameter (mm) Culvert Pipe Material Culvert Pipe Material - Select -SteelGalvanized SteelHigh-Density PolyethylenePolyvinyl ChlorideConcreteOther… Enter other… Provide the clearance or distances, vertical and horizontal, to the pipeline Weeping Tile Weeping Tile Fieldset Pipe Size Measurement (mm) Pipe Material Pipe Material - Select -Perforated High-Density PolyethyleneNon Perforated High-Density PolyethylenePolyvinyl ChlorideOther… Enter other… New Pipeline Construction Pipelines Pipelines Pipe Size (mm) Pipe Material Product Carried Seismic Include a map of the proposed program area in the attachments. Well Include a drawing indicating the distance from the gas line or right-of-way in the attachments. New Permanent Road Construction A road crossing profile is required to process your application. Ensure it is included in your project plan attachment(s) before submitting the form. Type - Select -New ConstructionExisting Road MaintenanceRoad Reclamation Surface SelectPavedGravel Ditch Work - Select -YesNo Provide the depth of excavation on the road surface (mm) Provide the ditch excavation depth (mm) Rail Crossing Include a new rail crossing profile in the attachments. Vehicle / Equipment Crossing List all vehicles and equipment you require as part of your project. List all vehicles and equipment you require as part of your project. Equipment - Make and Model Gross Loaded Weight (lbs.) Does the vehicle have wheels or tracks? SelectWheelsTracks Equipment - Make and Model Gross Loaded Weight (lbs.) Does the vehicle have wheels or tracks? SelectWheelsTracks Are vehicles highway legal without special permits? SelectYesNo Describe the type of work activity planned Attachments Include drawings and sketches to show your proposed work. Based on your responses above, ensure the following is demonstrated in your plans:* Legal Land Description * Permanent Road Construction * Seismic * Well * Rail Crossing Include drawings or sketches to show work and indicate the distance to the MIPL facility or pipeline. Include drawings Maximum 10 files.10 MB limit.Allowed types: GIF, JPG, JPEG, DOC, DOCX, BMP, PDF, PNG, PPT, PPTX, XLS, XLSX, VSD, DWG, DXR, DWF, TIF, TIFF. Acknowledgement MIPL will review your application for completeness and effect on MIPL infrastructure. If safe to do so, MIPL will issue a permit to cover the requested activities or will contact you if the work activities cannot proceed. Work MUST NOT proceed until signed contracts are in place. MIPL uses DocuSign to acquire contract signatures and to issue executed contracts. By selecting “I agree”, you acknowledge and agree the information provided is accurate and complete; are an authorized agent to make this request; acknowledge and agree to the use, collection, storage and retention of your personal information, and any other information you provide with this form in accordance with our Privacy Policy as applicable; accept that it is your responsibility to notify MIPL of any changes to the information provided. I Agree
