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Application for Interconnection Form rev 12-6-05.doc CITY OF ANAHEIM PUBLIC UTILITIES DEPARTMENT APPLICATION FOR INTERCONNECTION OF DISTRIBUTED GENERATION Customer Information Customer/Business Name Customer ID Location ID Address where generator is to be located Contact Person/Title Contact’s Address (if different than above) Telephone Fax Emergency Contact Name Emergency Contact Phone Description of Project Site Generator Information Category of Generator Induction Inverter Type of Generator Solar Photovoltaic Reciprocating Engine Microturbine Fuel Cell Other: Fuel Source Rated Unit Capacity (in kW) Number of Units Estimated Annual Energy Output (in kWh) Interconnection Voltage 1-phase 3-phase, 3-wire 3-phase, 4-wire Voltage: Main Panel 1-phase 3-phase Amps: Project Information Proposed Construction Start Date Generator On-Line Date Generator Operating Schedule (Days, Hours per week) Annual Operating Hours Customer Signature Date Electrical Engineering Review: T&D Initials / Date S/A Initials / Date