T.W. Phillips Pipeline Corp.

Original Volume No. 1

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Effective Date: 01/01/2010, Docket: RP10-141-000, Status: Effective

Original Sheet No. 100 Original Sheet No. 100

 

T. W. PHILLIPS PIPELINE CORP.

FORM OF TRANSPORTATION SERVICE REQUEST

 

SHIPPER INFORMATION

 

Complete legal name of Shipper:______________________________________________________________

 

State of Incorporation:______________________________________________________________________

 

Address:_______________________________________ Billing:_____________________________________

_______________________________________ Address:_____________________________________

_______________________________________ _____________________________________

Phone: _______________________________________ Phone: _____________________________________

 

Contact information for Notices: Contact information for scheduling

and volume information:

 

Name: _______________________________________ ___________________________________________

Address:_______________________________________ ___________________________________________

_______________________________________ ___________________________________________

_______________________________________ ___________________________________________

Phone: _______________________________________ ___________________________________________

E-mail: _______________________________________ ___________________________________________

 

Shipper is a (n)

_____ Local Distribution Company _____ Intrastate Pipeline

_____ Interstate Pipeline _____ Producer

_____ End User _____ Marketer

_____ Other (Specify)____________________________________________________

 

Name and full title of Officer, or other authorized person(s) who will execute the written trans-

portation agreement with Transporter. (If signatory person is not an Officer, please provide

written authorization for signature.)

 

Name:_________________________________________

Title:________________________________________

 

If person requesting service is an agent of Shipper, please provide proof of authority to act as

agent of Shipper and complete the following:

 

Legal Name of Principal:_______________________________________ which is a (n)

_____ Local Distribution Company _____ Intrastate Pipeline

_____ Interstate Pipeline _____ Producer

_____ End User _____ Marketer

_____ Other (Specify)____________________________________________________