American Midstream (Midla), LLC

Sixth Revised Volume No. 1

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Effective Date: 05/01/2010, Docket: RP10-483-000, Status: Effective

Original Sheet No. 364 Original Sheet No. 364

 

_____ Submit Confirmations, PDAs

Employee / Agent (circle one)

_____ Submit Nominations

Employee / Agent (circle one)

_____ View-only access to Interactive Internet Website screens, e-mail, web page and

reports for SHIPPER will be available to Customer?s Authorized Employee(s) and

Agent(s)

 

Signed by CUSTOMER?S Authorized Employee:

 

__________________________________________________ Date: ________________

 

Approved by Customer:____________________________________________

 

Title: ___________________________________________ Date: ___________________

 

Signed by CUSTOMER?S Authorized Agent:

 

__________________________________________________ Date: ________________

 

Approved by Customer:____________________________________________

 

Title: ___________________________________________ Date: ___________________

 

FOR INTERNAL USE ONLY

American Midstream (Midla), LLC Officer Signature:__________________________

 

Printed Name:

_____________________________________________________________

 

Title: ________________________________ Date:______________________________

 

 

USER ID: ______________________________ Customer# (if no DUNS):

______________

 

Security approved by:___________________ Date:

_____________________________

 

PLEASE FAX COMPLETED FORM TO (720) 457-6040