High Island Offshore System, L.L.C.

Third Revised Volume No. 1

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Effective Date: 11/27/2005, Docket: RP06- 53-000, Status: Effective

First Revised Sheet No. 179 First Revised Sheet No. 179 : Effective

Superseding: Substitute Original Sheet No. 179

 

 

Transportation Service Request Form

(Continued)

 

 

10. Producing Area of All Gas Supply Sources

 

Offshore Location Point of Measurement

 

(1) ______________________________ ______________________________

 

(2) ______________________________ ______________________________

 

(3) ______________________________ ______________________________

 

(If more space is required, please attach a listing).

 

11. Nature and Extent of Supplier's Affiliation with HIOS or Any member in HIOS (if

known): _______________________________________________________________________

 

12. State(s) of Ultimate End Use of the Gas: ______________________

 

13. (To be completed only if Shipper is affiliated with HIOS or any Member in HIOS,

and will be marketing the gas to be transported.)

 

Amount By Which the Gas Will Be Sold At a Loss ($/Dth): ___________________

 

14. Dun & Bradstreet Number: ___________________________________________________

 

15. Internet-E-Mail Address: ___________________________________________________

 

16. Certified Statement

 

By submitting this request, Shipper certifies that Shipper has or will have by

the time of execution of an Agreement with Transporter, title to the Gas or

right to deliver the Gas which is to be transported and owns facilities or has

contractual rights which will cause such Gas to be delivered to and received

from Transporter.

 

 

 

 

 

 

THIS TRANSPORTATION SERVICE REQUEST IS HEREBY SUBMITTED

 

this _______ day of ______________________, ____

 

By _______________________________________________

 

Title ____________________________________________

 

Telephone Number _________________________________