RUSH

Check the box if this is a RUSH application. Add $1,500 USD ($1,903 CAD) in addition to the application fee listed above.

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APPLICATION TERMS AND CONDITIONS :

Complete application package will include completion of all applicable fields, engineer stamped plans, certificate of insurance and confirmation of payment. Incomplete applications, including missing information in required fields, may result in processing delays. Applications submitted without the required fees will not be processed.

Please note, if the submitted application and plans require review by any independent environmental (HAZMAT) or other outside consultants, this review will be at applicant’s sole cost and in addition to the aforementioned fees.

***Canadian residents/businesses: this fee is a taxable supply, please include applicable GST***

STANDARD APPLICATION PROCESS IS 60-90 DAYS DEPENDING ON THE COMPLEXITY OF THE APPLICATION. REQUEST FOR RUSH SERVICE IS AVAILABLE WITH AN ADDITIONAL FEE. Once a COMPLETED application package and required fees are received, including the rush fee of $1,500 USD ($1,903 CAD), a draft agreement will be made available for review within twenty-one (21) business days, assuming submission of completed application. Please be sure to mark the RUSH box below for projects requiring expedited review.

If the application is approved, the applicant agrees to reimburse property owner for any cost incurred resulting from the installation, maintenance, and/or supervision and further agrees to assume all liability for accidents or injuries which arise as a result of this installation. In addition, annual fees will be assessed pursuant to a written lease agreement.

Once an executable agreement is submitted to you, this agreement must be fully negotiated and executed within thirty (30) days. If not executed, the application and materials will be archived and resubmission (including fees) will be required.

PLEASE INITIAL HERE INDICATING YOUR UNDERSTANDING OF THIS POLICY :

Upon submission of your application you will be provided with an opportunity number, please ensure to reference the opportunity number on the method of payment to ensure proper allocation. Send payment for the non-refundable fee of $6,000 USD ($7,611 CAD) to:

OmniTRAX, Inc.

C/O AR Real Estate Department

252 Clayton Street, 4th Floor

Denver, CO 80206

	RUSH
Check the box if this is a RUSH application. Add $1,500 USD ($1,903 CAD) in addition to the application fee listed above.

Provide Check Number

CERTIFICATE OF INSURANCE :

Upon submission of your application, you are required to submit a Certificate of Insurance. In addition, you will be required to obtain a CG 24 17 10 endorsement. Please ensure to name the Railroad as the Certificate Holder and that all required coverages are evidenced. Please review the templates for Certificate of Insurance and CG 24 17 10 Endorsement, linked here.

Railroad (Certificate Holder) :

Railroad Acronym

RR Record ID

Please attach the Certificate of Insurance, including all required coverages and naming the selected Certificate Holder

Section 1 - Customer Account Information :

Account Information

Is this application for a new customer account or an existing customer account ?

Mailing Account Information :

Account Name :

Mailing Street :

Mailing City :

Mailing State :

Mailing Zip Code :

Type of Entity (please select one) :

Federal Tax Identification number (U.S. Leases):

Account Contact First Name :

Account Contact Last Name :

Account Contact Title :

Account Contact Email :

Account Contact Phone :

If applicable, State/Province of incorporation or organization :

Email Address Where Notices Can be Sent to :

Overnight Delivery Service Address (if different) :

Billing Account Information (Complete this section on behalf of the entity responsible for annual Agreement payments) :

Same as Mailing Account

Yes No

Billing Account Same as Mailing Account :

Billing Account Name :

Billing Contact First Name :

Billing Contact Last Name :

Billing Contact Phone Number :

Billing Street :

Billing City :

Billing State :

Billing Zip Code :

Billing Contact Email (where to send invoices) :

New Billing Account :

New Billing Account Name :

Billing Contact First Name :

Billing Contact Last Name :

Billing Contact Phone Number :

Billing Street :

Billing City :

Billing Sate :

Billing Zip Code :

Billing Contact Email (where to send invoices) :

Hidden Fields :

ABV. APP TYPE

Application Type

Agreement Type

Application Status :

Source of Opportunity :

Page 3

Section 2 - Location Details of Pipe Line:

Railroad

Subdivision :

Nearest Milepost :

DOT No. :

Property Address/Street :

Property City :

Property State or Providence :

Property County :

Property Country :

Opportunity Currency :

Section :

Township :

Range :

Geographical Coordinates Required (Decimal Degrees DD):

Property Coordinate (Latitude) :

Property Coordinate (Longitude) :

Located on the (N/S/E/W) side of (landmark, intersection) :

Section 3 - Engineering Plans :

Proposed plans must adhere to the Railroad's Utility Accommodation Policy, be approved by the railroad, and a crossing agreement must be fully executed between the railroad and the applicant before construction can begin. Materials and installation are to be in strict accordance with specifications of the American Railway Engineering Association and requirements of the railroad. Submission of this form shall be accompanied with engineer stamped plans, elevation section of crossing from field survey, location in respect to Mile Post, width of railroad right of way, location of adjacent structures that may impede the crossing, and all information required in Figures 1 and 2 of AREMA Specifications, Part 5. If open cutting or tunneling is necessary, details of sheeting and method of supporting tracks or driving tunnel shall be shown.

If you have not reviewed Railroad's Utility Accommodation Policy, please review the document prior to submittal of this application.

Provide location (i.e. city, street, railroad milepost) and engineer stamped plans of the proposed leased premises with dimensions, coordinates and directions. Also depict any planned improvements on the leased premises with dimensions from nearest track (may incur additional costs or agreements for above ground occupancy).

All specifications meet or exceed Railroad’s Utility Accommodation Policy OR Variance requested below INITIAL HERE :

Check if the Variance to policy is requested :

Yes

If a variance to the policy is requested, PLEASE DESCRIBE IN DETAIL (Include requested variance detail in plan submission) :

Please attach the detailed, Engineer Stamped, plans for your project below :

Product Category

Product Sub-Category

Section 4 - Orientation of Pipe Line :

Will the Pipeline placement be perpendicular or parallel to the Railroad Right of Way ?

Total Longitudinal Length :

(Distance of parallelism / distance within Railroad right-of-way in Feet)

Total perpendicular length within Railroad right-of-way (Feet) :

Angle between centerline of right-of-way and pipeline (degrees) :

Number of tracks to be crossed :

Page 4

Section 5 - Pipe Line Information :

Will temporary track support or rewrapping required ?

If yes, please describe :

Is the commodity Flammable ?

If yes, please provide description:

Max. Working Pressure:

PSI

Field Test Pressure:

PSI

Type of Test :

Location of shut-off valve :

BURY (Roadway pipe) Ft :

Inches:

BURY (Not beneath tracks) Ft

Inches:

BURY: Base of rail to top of casing (Ft)

Inches:

SEALS :

One end

Number of VENTS:

Size(Inches)

Ht. above ground(Feet)

PROTECTIVE COATING :

Kind :

CATHODIC PROTECTION:

Method of Installation :

Type, size, and spacing of insulators or supports :

Pipe Line Specification :

CARRIER PIPE	CASING PIPE
Material	Material
Material Specifications and Grade	Material Specifications and Grade
Min. Yield Strength of Mat. PSI	Min. Yield Strength of Mat. PSI
Mill Test Pressure PSI	Mill Test Pressure PSI
Inside Carrier Pipe Diameter (inches)	Inside Casing Diameter (inches)
Wall Thickness (inches)	Wall Thickness (inches)
Outside Carrier Pipe Diameter (Inches)	Outside Casing Diameter (Inches)
Type of Seam	Type of Seam
Laying Lengths (Feet)	Laying Lengths (Feet)
Kind of Joints	Kind of Joints

Existing Agreement

Is this Pipeline being added to an existing crossing under agreement?

Lease Number :

Lease Date :

Will Wires, Poles, obstructions to be relocated?

If yes, please describe :

By submitting this application for credit, you authorize OmniTRAX or it's affiliates, to make any inquiries necessary to determine credit worthiness. You release your banking instruction release details that would assist to determine credit worthiness.

I hereby certify that the information contained herein is complete and accurate. This information has been furnished with the understanding that it is to be used to determine the amount and conditions of the credit to be extended. Furthermore, I hereby authorize the financial institutions listed in this credit application to release necessary information to the company for which credit is being applied for in order to verify the information contained herein. Our terms of sale and service are NET 30 DAYS from the date listed on the invoice. Invoices that are beyond granted terms will be assessed a late fee of 18% APR (1.5% monthly) additional Terms and Conditions apply. A $20.00 charge will apply for any NSF/Non-Sufficient Checks.

Applicant Contact Information

LIST CHECK NUMBERS :

Applicant Contact First Name :

Applicant Contact Last Name :

Applicant Contact Email :

Applicant Contact Phone :

Applicant Date :

Applicant Signature :

JV Test Section (Account Contact Fields/Disregard for now)

Mailing State Code

Field for Account Name lookup

Account Name 1

Please select the Mailing State first to add the account name.

Account ID from Dynamic Picklists (HIDDEN)

Account Contact First Name

Account Contact Last Name

Account Contact Emails

Opportunity Closed Date

Rush Application

Regular Application

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