Request Date / Date to Fuel Expected Delivery Date PO Required?*YesNoPO #CUSTOMER & LOCATION INFORMATIONCustomer Name*ShipTo / Well Name*SalespersonCell PhoneRound Trip MileageRegion*WTXSTXETXLAWithin City Limits*YesNoAddressCityState*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code*LatitudeLongitudeLocation NotesLine of Business* Frac 1000 Routes 2000 Rigs 3000 MFUS 4000 Tomahawk 5000 Auto 7000 Product* Clear 4000 Dyed 4100 87E10 7000 93E0 3000 87E0 1000 PRICINGOPIS Region*WTXSTXETXLAOPIS ScaleHighAverageMarginFreightTax ScheduleSPECIAL REQUESTS & PRICING ARRANGEMENTSSpecial Pricing Arrangements?*Any special requirements or misc. item(s) being sold outside standard rate(s)?YesNoSpecial Requests & / Or Pricing RequirementsStamp Required*YesNoSignature Required*YesNoConsolidated*YesNoSplit By Well*YesNoBilling Requiring*Shift24 HrDay24 Hour Shift Time*12 AM to 12 AM6 PM to 6 PMFrac Job OverviewOperator*Operator Responsible Party Responsible Party Pressure Pumping Co.Pressure Pumping Responsible Party Responsible Party Job TypeNight Crew Requested for Possible Move Up TimeYesNoTotal StagesMax PSIMax RatePump TimeOper. DaysContainmentsDirectionsSpecial InstructionsSite Supervisors / POCNameEmail OfficeCellFaxSite Supervisors / POCNameEmail OfficeCellFaxSide Fuel / 3rd PartiesCoil TubingCoil Tubing Responsible Party Yes WirelineWireline Responsible Party Yes Pump DownPump Down Responsible Party Yes Lighting PlantsLighting Plants Responsible Party Yes Water TransferWater Transfer Responsible Party Yes OtherOther Responsible Party Yes
