Riverside Pipeline Company, L. P.

First Revised Volume No. 1

Effective Date: 10/01/1993, Docket: RS92- 48-001, Status: Effective

Original Sheet No. 122 Original Sheet No. 122 : Effective

GENERAL TERMS AND CONDITIONS

APPENDIX A

SERVICE REQUEST FORM

Riverside Pipeline Company, L.P. Date_____________________

9200 Indian Creek Parkway

Building 9, Suite 180

Overland Park, KS 66210

ATTENTION: Transportation Services Department

Gentlemen:

_______________________________________ (Shipper) hereby requests service

from Riverside Pipeline Company, L.P (Riverside) pursuant to Section 11 of

the General Terms and Conditions of its tariff and concurrently provides the

following information in connection with this request:

1. Request is for (check as appropriate):

a. New Service Agreement (only one per request) ____

i. Firm Transportation Service (FT) ____

ii. Interruptible Transportation Service (IT) ____

b. Amendment to an existing agreement #_______ Date________ ____

i. change in primary receipt point(s) ____

ii. change in primary delivery point(s) ____

iii. other (describe) ____

_____________________________________________________

2. Shipper Information:

a. Complete legal name of Shipper:

___________________________________________________________