Utility:
Customer:
Name: _________________________________________________
Address: _______________________________________________
_______________________________________________
_______________________________________________
Utility Account No.: ____________________________________
Agent (if any):
Name: _______________________________________________
Address: _____________________________________________
_______________________________________________
Consulting Engineer or Contractor:
Name: ________________________________________________
Address:______________________________________________
______________________________________________
Existing Electric Service:
Capacity: __________ Amperes
Voltage: __________ Volts
Service Character: ( ) Single Phase ( ) Three Phase
Phone: ( _____ ) ________________________________________
Fax: ( _____ ) ___________________________________________
Email: _________________________________________________
Municipality: __________________________________________
Utility Meter No.: ______________________________________
Phone: ( _____ ) _____________________________________
Fax: ( _____ ) _________________________________________
Email: _______________________________________________
Phone: ( ) ________________________________________
Fax: ( _____ ) _________________________________________
Email: _______________________________________________
Location of Protective Interface Equipment on Property:
(Include address if different from customer address.)
Energy Producing Inverter Information:
Total AC Nameplate Rating of All Inverters:
Inverter
Inverter or System Tested to UL 1741 (most current version):
( ) Yes ( ) No If no, attach product literature.
Manufacturer: _______________________ Model: _____________
Quantity:
Rating per inverter: __________ kW
Type:
( ) Forced Commutated ( ) Line Commutated
( ) Utility Interactive ( ) Stand Alone
Rated Output: ________ Amperes ________ Volts
Ramp Rate:
Method of Grounding: ( ) Grounded ( ) Ungrounded
Quantity of Inverters: _____________
If there is more than one inverter of different types of manufacturers, please provide information on a separate sheet.
If applicable:
Step Up Transformer Winding Configuration:
( ) Wye-Wye ( ) Wye-Delta ( ) Delta-Wye
Other existing DG such as emergency generators, other renewable technologies, microturbines, hydro, fuel cells, battery storage, etc:
( ) Yes ( ) No
If yes, provide information about existing generation on separate sheet and include detail on single-line diagram.
Signature:
_____________________________________________________________ ______________________________________ __________________
CUSTOMER/AGENT SIGNATURE TITLE DATE