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. 214 Original Sheet No. 214

Revision No. _________

Exhibit A to Hub Services Agreement No. _________

Under Rate Schedule ___

Between

PetroLogistics Natural Gas Storage LLC (PetroLogistics)

And ___________________________ (Shipper)

SHIPPER: _________________________ pursuant to the Hub Services Agreement executed by Shipper

on __________, hereby directs and requests to PetroLogistics to do the following.

Title Transfer: (from) Title Transfer: (from)

Company Name:__________________ Company Name:__________________

Phone:___________ Fax:___________ Phone:___________ Fax:___________

RECEIPT POINT(S)

Flow

Pipeline Name

Location Meter Name &

Volume

Shipper's Name

Shipper's

Date

Meter Number (Dth/d)

Contract Number

__________________ ______________________

____________________________________

______________ ____________________________

______________________________ ______________

_____________________________________________________

Maximum Daily Receipt Quantity _______Dth (as applicable)

DELIVERY POINT(S)

Flow

Pipeline Name

Location Meter Name &

Volume

Shipper's Name

Shipper's

Date

Meter Number

(Dth/d)

Contract Number

____ ______________ ____________________

____________________________________ ______________

__________________________________________

______________ ______________ ____________________

________________________________

Maximum Daily Delivery Quantity _______Dth (as applicable)

Comments:______________________________________________________________________

___________________________ Maximum Imbalance Trading Quantity ______________ Dth

Requested Service or Components Thereof

Maximum Park Quantity _____________ Dth Maximum Daily Wheeling Quantity

_____________ Dth Maximum Balancing Quantity _____________ Dth Maximum Loan Quantity

_____________ Dth Maximum Daily Injection Quantity _____________ Dth Maximum Daily

Withdrawal Quantity _____________ Dth