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. 365 Original Sheet No. 365

 

TRANSPORTATION SERVICE REQUEST FORM

 

American Midstream (Midla), LLC

Attention: Contract Administration

1614 15th Street, Suite 300

Denver, CO 80202

 

Telephone No. (720) 457-6077

Fax No. (720) 457-6040

 

Re: New Service _ Interruptible Service

or or

Amendment Firm Service

 

(Contract # _______________)

 

(Description of existing service to be amended):

__________

 

Sir or Madam:

 

(Customer) hereby requests transportation service from

American Midstream (Midla), LLC (Pipeline) and concurrently provides the following

information in connection with this request:

 

1. Complete legal name of Customer:

________________________________________

 

2. Duns Number: __________________________Fed Tax

ID:______________________

3. Type of legal entity and State of Incorporation or Formation:

 

Type of company:

End User LDC

Hinshaw Marketer

Interstate Producer

Intrastate Other (fill in)

___________________________

 

 

5. Contact, address and telephone number for Notices:

_____

Contact, address and telephone number for Invoices: