Installation Request Form

CONTACT INFORMATION

Builder/Customer requesting work (required):

Scheduling contact name (required):

Scheduling contact phone (required):

Scheduling contact email (required):

Today's Date:

Installation date requested:

Site Location
Address (Ave, St, Ln, etc):

City:

State:

Zip Code:

NATURAL GAS INSTALLATION

Install required?
YesNo

Meter tie in required? (city of mesa only)
YesNo

Will a regulator be required at the Meter (2lb system)?
YesNo

SOUTHWEST GAS TRENCH AND SLEEVE INFORMATION

** SWG has requested that you provide a trench and sleeve for new natural gas to your home or place of business

Is this a residential or commercial property?
CommercialResidential

Footage of SWG trench and sleeve required from property line to new gas meter location:

PROPANE INSTALLATION

Install required?
YesNo

Is RP Gas providing the propane tank?
YesNo

What size gallon tank? :
(2) 231202505001000
Tank placement noted on plan?
YesNo
Tank installation type:
Above GroundUnderground
High pressure system (a regulator is required at each appliance)?
YesNo
Low pressure system (one regulator at the tank)?
YesNo

PERMIT INFORMATION

Who will provide the permit?
RP GasBuilder

Please upload the copy of your permit (.PDF preferred/max size 2mb)

If RP Gas is responsible for the permit please upload your site plan (.PDF preferred/max size 2mb)

LAND INFORMATION

Hand dig required?
YesNo

If yes, please enter the footage:

Will any tunneling or boring be needed?
YesNo

If yes, please enter the footage:

Rocky soil conditions or hard dig?
YesNo

APPLIANCE INFORMATION

Install the following footage of PE PIPE to appliances
(please enter the footage for each desired size)

2” PE (footage):

1 1/2” PE (footage):

1 1/4” PE (footage):

1” PE (footage):

3/4” PE (footage):

Heater 250k or 400k (qty):

BBQ (qty):

Firepit (qty):

Fireplace (qty):

Firebar (qty):

TIKI's (qty):

Custom Fire Feature (qty):

Other appliances (qty):

OTHER

Standard Key valve installation?
YesNo

If yes, please enter the qty:

High Capacity Key valve installation?

YesNo

If yes, please enter the qty:

**Required for rings larger than 24" and fire bars longer than 48"

BBQ hookup?
YesNo

If yes, please enter the qty:

FIRE FEATURES

Fire ring or firebar installation?
YesNo

If yes, please enter the quantity of each desired size:
FIRE RINGS
12" ring (qty):

18" ring (qty):

24" ring (qty):

30" ring (qty):

36" ring (qty):

FIREBARS

24" bar (qty):

36" bar (qty):

48" bar (qty):

60" bar (qty):

72" bar (qty):

84" bar (qty):

Custom Size (qty):

Special request or instructions:

*NOTE: Please inform your customers that Southwest gas will be responsible for the gas meter tie into the riser.

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