K N Wattenberg Transmission LLC

Original Volume No. 1

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Effective Date: 04/01/1993, Docket: CP92-203-002, Status: Effective

Original Sheet No. 67 Original Sheet No. 67 : Effective

 

 

TRANSPORTATION SERVICE REQUEST FORM

 

SHIPPER INFORMATION

 

Complete Legal Name of Shipper: _________________________________________

State of Incorporation: _________________________________________________

 

Address: _______________________ For Billing: ________________________

_______________________ ________________________

_______________________ ________________________

Phone: _______________________ Phone: ________________________

 

For Notices: For Scheduling and Volume Information:

(include street address for express service)

Contact Name: _____________________ ________________________

_____________________ ________________________

_____________________ ________________________

Phone: _____________________ Phone: ________________________

 

Shipper is: ___ Local Distribution Company ___ Intrastate Pipeline

___ Interstate Pipeline ___ Producer

___ End User ___ Marketer

___ Other (specify) ______________________________________

 

Name and full title of Officer or General Partner who will execute the

written distribution service 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) _______________________________________________