PHMSA form 7000.1

NOTICE: This report is required by 49 CFR Part 191. Failure to report can result in a civil penalty not to exceed $100,000 for each violation Form Approved
for each day the violation continues up to a maximum of $1,000,000 for any related series of violations as provided in 49 USC 60122. OMB No. 2137-0522

U.S. Department of Transportation Pipeline and Hazardous Materials Safety Administration		INCIDENT REPORT - GAS DISTRIBUTION SYSTEM					Report Date No. (DOT Use Only)
INSTRUCTIONS
Important: Please read the separate instructions for completing this form before you begin. They clarify the information requested and provide specific examples. If you do not have a copy of the instructions, you can obtain one from the Office Of Pipeline Safety Web Page at http://ops.dot.gov.
PART A – GENERAL REPORT INFORMATION			Check: ¨ Original Report ¨ Supplemental Report ¨ Final Report
1. Operator Name and Address a. Operator's 5-digit Identification Number / / / / / / If Operator does not own the pipeline, enter Owner’s 5-digit Identification Number / / / / / / Name of Operator _____________________________ _______________________________________________________ Operator street address ________________________________________________________________________________________ Operator address _______________________ City, County or Parish, State and Zip Code
2. Time and date of the incident / / / / / / / / / / / / / / hr. month day year 3. Incident Location a. Street or nearest street or road b. City and County or Parish c. State and Zip Code d. Latitude: / / / / / / Longitude: / / / / / / (if not available, see instructions for how to provide specific location) e. Class location description ¡ Class 1 ¡ Class 2 ¡ Class 3 ¡ Class 4 f. Incident on Federal Land ¡ Yes ¡ No 4. Type of leak or rupture ¡ Leak: ¡Pinhole ¡Connection Failure (complete sec. F5) ¡ Puncture, diameter or cross section (inches)____ ¡ Rupture (if applicable): ¡ Circumferential – Separation ¡ Longitudinal - Tear/Crack, length (inches) _______ - Propagation Length, total, both sides (feet) ¡ N/A ¡ Other: _____________________				5. Consequences (check and complete all that apply) a. ¨ Fatality Total number of people: / / / / Employees: / / / / General Public: / / / / Non-employee Contractors: / / / / b. ¨ Injury requiring inpatient hospitalization Total number of people: / / / / Employees: / / / / General Public: / / / / Non-employee Contractors: / / / / c. ¨ Property damage/loss (estimated) Total $ Gas loss $ Operator damage $ Public/private property damage $ d. ¨ Gas ignited ¡ Explosion ¡ No Explosion e. ¨ Gas did not ignite ¡ Explosion ¡ No Explosion f. ¨ Evacuation (general public only) / / / / / people Evacuation Reason: ¡ Unknown ¡ Emergency worker or public official ordered, precautionary ¡ Threat to the public ¡ Company policy 6. Elapsed time until area was made safe: / / / hr. / / / min. 7. Telephone Report / / / / / / / / / / / / / / / / NRC Report Number month day year 8. a. Estimated pressure at point and time of incident: PSIG b. Max. allowable operating pressure (MAOP): PSIG c. MAOP established by: ¡ Test Pressure __________ psig ¡ 49 CFR § 192. 619 (a)(3)
PART B – PREPARER AND AUTHORIZED SIGNATURE
(type or print) Preparer's Name and Title						Area Code and Telephone Number
Preparer's E-mail Address						Area Code and Facsimile Number
Authorized Signature (type or print) Name and Title					Date	Area Code and Telephone Number

Form PHMSA F 7100.1 (03-04) Reproduction of this form is permitted Page 1 of 3

PART C - ORIGIN OF THE INCIDENT

1. Incident occurred on ¡ Main ¡ Meter Set ¡ Service Line ¡ Other: __________________________ ¡ Pressure Limiting and Regulating Facility 2. Failure occurred on ¡ Body of pipe ¡ Pipe Seam ¡ Joint ¡ Component ¡ Other:

3. Material involved (pipe, fitting, or other component) ¡ Steel ¡ Cast/Wrought Iron ¡ Polyethelene Plastic (complete all items that apply in a-c) ¡ Other Plastic (complete all items that apply in a-c) Plastic failure was: ¨ a.ductile ¨ b.brittle ¨ c.joint failure ¡ Other material: _________ 4. Year the pipe or component which failed was installed: / / / / /

PART D – MATERIAL SPECIFICATION (if applicable)

PART E – ENVIRONMENT

1. Nominal pipe size (NPS) / / / / / in. 2. Wall thickness / / / / / in. 3. Specification SMYS / / / / / / / 4. Seam type

1. Area of incident ¡ In open ditch ¡ Under pavement ¡ Above ground ¡ Under ground ¡ Under water ¡ Inside/under building ¡ Other: 2. Depth of cover: inches

5. Valve type 6. Pipe or valve manufactured by in year / / / / /

PART F – APPARENT CAUSE

Important: There are 25 numbered causes in this section. Check the box to the left of the primary cause of the incident. Check one circle in each of the supplemental items to the right of or below the cause you indicate. See the instructions for this form for guidance.

F1 – CORROSION

If either F1 (1) External Corrosion, or F1 (2) Internal Corrosion is checked, complete all subparts a – e.

1. o External Corrosion

a. Pipe Coating ¡ Bare ¡ Coated ¡ Unknown

b. Visual Examination ¡ Localized Pitting ¡ General Corrosion ¡ Other: ____________________

c. Cause of Corrosion ¡ Galvanic ¡ Stray Current ¡ Improper Cathodic Protection ¡ Microbiological ¡ Other: ____________________

2.o Internal Corrosion

d. Was corroded part of pipeline considered to be under cathodic protection prior to discovering incident? ¡ No ¡ Yes ¡ Unknown Year Protection Started: / / / / / e. Was pipe previously damaged in the area of corrosion? ¡ No ¡ Yes ¡ Unknown How long prior to incident: / / / / years / / / months

F2 – NATURAL FORCES 3. o Earth Movement  ¡ Earthquake ¡ Subsidence ¡ Landslide ¡ Other: 4. o Lightning 5. o Heavy Rains/Floods  ¡ Washouts ¡ Flotation ¡ Mudslide ¡ Scouring ¡ Other: 6. o Temperature  ¡ Thermal stress ¡ Frost heave ¡ Frozen components ¡ Other: 7. o High Winds F3 - EXCAVATION 8. o Operator Excavation Damage (including their contractors) / Not Third Party

9. o Third Party Excavation Damage (complete a-d) a. Excavator group ¡ General Public ¡ Government ¡ Excavator other than Operator/subcontractor b. Type: ¡ Road Work ¡ Pipeline ¡ Water ¡ Electric ¡ Sewer ¡ Phone/Cable/Fiber ¡ Landowner ¡ Railroad ¡ Building Construction ¡ Other: c. Did operator get prior notification of excavation activity? ¡ No ¡ Yes: Date received: / / / mo. / / / day / / / yr. Notification received from: ¡ One Call System ¡ Excavator ¡ General Contractor ¡ Landowner d. Was pipeline marked? ¡ No ¡ Yes (If Yes, check applicable items i – iv) i. Temporary markings: ¡ Flags ¡ Stakes ¡ Paint ii. Permanent markings: ¡ Yes ¡ No iii. Marks were (check one) ¡ Accurate ¡ Not Accurate iv. Were marks made within required time? ¡ Yes ¡ No F4 – OTHER OUTSIDE FORCE DAMAGE 10. o Fire/Explosion as primary cause of failure  Fire/Explosion cause: ¡ Man made ¡ Natural Describe in Part G 11. o Car, truck or other vehicle not relating to excavation activity damaging pipe 12. o Rupture of Previously Damaged Pipe 13. o Vandalism

Form PHMSA F 7100.1 (03-04 ) Page 2 of 3

F5 – MATERIAL OR WELDS Material 14. o Body of Pipe  ¡ Dent ¡ Gouge ¡ Wrinkle Bend ¡ Arc Burn ¡ Other: 15. o Component  ¡ Valve ¡ Fitting ¡ Vessel ¡ Extruded Outlet ¡ Other: 16. o Joint  ¡ Gasket ¡ O-Ring ¡ Threads ¡ Fusion ¡ Other: Weld 17. o Butt  ¡ Pipe ¡ Fabrication ¡ Other: 18. o Fillet  ¡ Branch ¡ Hot Tap ¡ Fitting ¡ Repair Sleeve ¡ Other: 19. o Pipe Seam  ¡ LF ERW ¡ DSAW ¡ Seamless ¡ Flash Weld o ¡ HF ERW ¡ SAW ¡ Spiral ¡ Other:
Complete a-f if you indicate any cause in part F5. a. Type of failure: o Construction Defect  ¡ Poor Workmanship ¡ Procedure not followed ¡ Poor Construction Procedures o Material Defect b. Was failure due to pipe damage sustained in transportation to the construction or fabrication site? ¡ Yes ¡ No c. Was part which leaked pressure tested before incident occurred? ¡ Yes, complete d-f, if known ¡ No d. Date of test: / / / mo. / / / day / / / yr. e. Time held at test pressure: / / / hr. f. Estimated test pressure at point of incident: PSIG
F6 – EQUIPMENT OR OPERATIONS 20. o Malfunction of Control/Relief Equipment  ¡ Valve ¡ Instrumentation ¡ Pressure Regulator ¡ Other: 21. o Threads Stripped, Broken Pipe Coupling  ¡ Nipples ¡ Valve Threads ¡ Mechanical Couplings ¡ Other: 22. o Leaking Seals
23. o Incorrect Operation a. Type: ¡ Inadequate Procedures ¡ Inadequate Safety Practices ¡ Failure to Follow Procedures ¡ Other: b. Number of employees involved in incident who failed post-incident drug test: / / / / Alcohol test: / / / / c. Was person involved in incident qualified per OQ rule? ¡ Yes ¡ No d. Hours on duty for person involved: / / /
F7 – OTHER 24. o Miscellaneous, describe: 25. o Unknown ¡ Investigation Complete ¡ Still Under Investigation (submit a supplemental report when investigation is complete)
PART G – NARRATIVE DESCRIPTION OF FACTORS CONTRIBUTING TO THE EVENT	(Attach additional sheets as necessary)

Form PHMSA F 7100.1 (03-04 ) Page 3 of 3