PetroLogistics Natural Gas Storage LLC

Original Volume No. 1

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Effective Date: 06/03/2009, Docket: RP09-577-000, Status: Effective

Original Sheet No. 213 Original Sheet No. 213

Exhibit A to Hub Services Agreement No. _________

Under Rate Schedule ___

Between

PetroLogistics Natural Gas Storage LLC (PetroLogistics)

And

___________________________ (Shipper)

Receipt and/or Delivery Points:

PIPELINE

METER #

PARISH

STATE