Service Request Form

Dillman Services, Inc

Service Request Form

Please fill out as completely as possible.

Company Name* Lease Name Requested Date Pumper/Operator Name* Phone Number* Email Address* Description of Problem or Questions

Need Written Treating Recommendations Need Verbal Clairification of Treating Recommendations Oil Problems (Emulsion, Paraffin, Water Content) Water Problems (Injection issues, Bacteria, Scale, Corrosion) Injection Permit Water Analysis Other (Please Describe)

Directions to Lease
(If not your current supplier)