B-R Pipeline Company

Original Volume No. 1

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Effective Date: 05/01/2004, Docket: RP04-224-000, Status: Effective

Original Sheet No. 121 Original Sheet No. 121 : Effective

GENERAL TERMS AND CONDITIONS

(CONTINUED)

24. FORM OF TRANSPORTATION REQUEST

B-R PIPELINE COMPANY ("Transporter")

Transportation Request

Shipper Information

1. Shipper Name: __________________________________________________

(Legal Name of Party who will be signing Agreement)

(a) Requester: ________________________________________________

(if other than Shipper)

2. Shipper is (Check One)

_____ End User _____ Hinshaw Pipeline

_____ LDC _____ Producer

_____ Interstate Pipeline _____ Marketer

_____ Intrastate Pipeline _____ Other_____________________

(please specify)

3. Shipper's Contact Person ______________________________________

Phone Number (___)_________________________________

Telecopy Number (___)_________________________________

4. Address: Notices to: ______________________________________

P.O. Box & Zip ______________________________________

Street & Zip ______________________________________

City, State ______________________________________

Attention ______________________________________

Email Address: ______________________________________

Invoices to: ______________________________________

P.O. Box & Zip ______________________________________

Street & Zip ______________________________________

City, State ______________________________________

Attention ______________________________________

Regulatory/"On Behalf of" Information

5. Shipper hereby requests:

___ Section 311 transportation pursuant to Section 284.102 for service on

behalf of a local distribution company or an intrastate pipeline.

___ Open access transportation pursuant to Section 284.222 for service on

behalf of an interstate pipeline.

___ Open access transportation pursuant to Section 284.223 for service on

behalf of a shipper other than an interstate pipeline.

___ Not Applicable

6. If service is requested pursuant to Section 284.102 above, identify

the "on behalf of" party associated with the transportation service

requested:

Legal Name: ____________________________________________________