Southern LNG Inc.

Original Volume No. 1

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Effective Date: 12/01/2001, Docket: CP99-582-004, Status: Effective

Original Sheet No. 112 Original Sheet No. 112 : Effective

GENERAL TERMS AND CONDITIONS

(Continued)

ATTACHMENT A TO APPENDIX A

SERVICE REQUEST FORM

VESSEL INFORMATION

Customer:

LNG Tanker(s) Register LNG Cargo LNG Tanker

Name(s) Register Number Flag Capacity (Mcf) Owner/Operator/Manager