Crossroads Pipeline Company

First Revised Volume No. 1

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Effective Date: 11/01/2001, Docket: RP02- 14-000, Status: Effective

Original Sheet No. 518 Original Sheet No. 518 : Effective

REQUEST FOR SERVICE

SHIPPER NAME OR ADDRESS CHANGE

1. Changes are applicable to:

Rate Schedule ______________ Agreement No. _______________

ALL ______________

2. Identity of Requestor

Legal Company Name ____________________________________________________________________

Abbreviation or short name (if applicable)_____________________________________________

Phone Number _____________________________

Facsimile Number _________________________

ADDRESSES FOR NEW AGREEMENT

MAILING

Street _____________________________________________________________________________________

City _____________________________________________________________________________________

State _____________________________________________________________________________________

Zip Code ___________________________________________________________________________________

Contact Person (Mr., Mrs., Miss, Ms.) ______________________________________________________

BILLING (if different than Mailing)

Street _____________________________________________________________________________________

City _____________________________________________________________________________________

State _____________________________________________________________________________________

Zip Code ___________________________________________________________________________________

Contact Person (Mr., Mrs., Miss, Ms.) ______________________________________________________