Request Date / Date to Fuel Expected Delivery Date PO Required?*YesNoPO #CUSTOMER & LOCATION INFORMATIONCustomer Name*ShipTo / Well Name*SalespersonRound 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 Product* Clear 4000 Dyed 4100 87E10 7000 93E0 3000 87E0 1000 PRICINGOPIS Region*WTXSTXETXLAOPIS ScaleHighAverageMarginFreightTax ScheduleSPECIAL REQUESTS & PRICING ARRANGEMENTSSpecial Pricing Arrangements?*Any special pricing arrangement(s) or misc. item(s) being sold outside standard rate(s)?YesNoSpecial Requests & / Or Pricing RequirementsFrac Job OverviewOperator*Pressure Pumping Co.Job TypeNight Crew Requested for Possible Move Up TimeYesNoTotal StagesMax PSIMax RatePump TimeOper. DaysContainmentsDirectionsSite Supervisors / POCNameEmail OfficeCellFaxSite Supervisors / POCNameEmail OfficeCellFaxPel-State Operations Rep.NameEmail OfficeCellFaxPel-State Sales Rep.NameEmail OfficeCellFaxSide Fuel / 3rd PartiesFracking CompanyFracking Company Responsible PartyWirelineWireline Responsible PartyPump DownPump Down Responsible PartyLighting PlantsLighting Plants Responsible PartyWater TransferWater Transfer Responsible Party
