PHMSA form 7100.1-1

NOTICE: This report is required by 49 CFR Part 191. Failure to report may 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 as provided in 49 USC 60122. OMB No. 2137-0522

U.S. Department of Transportation Pipeline and Hazardous Materials Safety Administration

ANNUAL REPORT FOR CALENDAR YEAR 20___ GAS DISTRIBUTION SYSTEM

INITIAL REPORT ¨ SUPPLEMENTAL REPORT ¨

PART A - OPERATOR INFORMATION

DOT USE ONLY

1. NAME OF OPERATOR

3. OPERATOR'S 5 DIGIT IDENTIFICATION NUMBER

/ / / / / /

2. LOCATION OF OFFICE WHERE ADDITIONAL INFORMATION MAY BE OBTAINED

4. HEADQUARTERS NAME & ADDRESS, IF DIFFERENT

Number and Street

Number and Street

City and County

City and County

State and Zip Code

State and Zip Code

5. STATE IN WHICH SYSTEM OPERATES:/ / / (provide a separate report for each state in which system operates)

PART B - SYSTEM DESCRIPTION

Report miles of main and number of services in system at end of year.

1. GENERAL

STEEL

CAST/ WROUGHT IRON

UNPROTECTED

CATHODICALLY PROTECTED

PLASTIC

DUCTILE IRON

COPPER

OTHER

OTHER

TOTAL

BARE

COATED

BARE

COATED

MILES OF MAIN

NO. OF SERVICES

2. MILES OF MAINS IN SYSTEM AT END OF YEAR

MATERIAL

UNKNOWN

2" OR LESS

OVER 2" THRU 4"

OVER 4" THRU 8"

OVER 8" THRU 12”

OVER 12"

TOTAL

STEEL

DUCTILE IRON

COPPER

CAST/WROUGHT IRON

PLASTIC 1. PVC

2. PE

3. ABS

OTHER

OTHER

SYSTEM TOTALS

3. NUMBER OF SERVICES IN SYSTEM AT END OF YEAR AVERAGE SERVICE LENGTH FEET

MATERIAL

UNKNOWN

1" OR LESS

OVER 1" THRU 2"

OVER 2" THRU 4"

OVER 4" THRU 8”

OVER 8"

TOTAL

STEEL

DUCTILE IRON

COPPER

CAST/WROUGHT IRON

PLASTIC 1. PVC

2. PE

3. ABS

OTHER

OTHER

SYSTEM TOTALS

Form PHMSA F 7100.1-1 (12-05)

Reproduction of this form is permitted.

4. MILES OF MAIN AND NUMBER OF SERVICES BY DECADE OF INSTALLATION

UN-KNOWN

PRE-1940

1940-1949

1950- 1959

1960- 1969

1970- 1979

1980– 1989

1990– 1999

2000– 2009

TOTAL

MILES OF MAIN

NUMBER OF SERVICES

PART C - TOTAL LEAKS ELIMINATED/REPAIRED DURING YEAR

PART D - TOTAL NUMBER OF LEAKS ON FEDERAL LAND REPAIRED OR SCHEDULED FOR REPAIR

CAUSE OF LEAK

Mains

Services

CORROSION

NATURAL FORCES

EXCAVATION

OTHER OUTSIDE FORCE DAMAGE

PART E - PERCENT OF UNACCOUNTED FOR GAS

MATERIAL OR WELDS

Unaccounted for gas as a percent of total input for the12 months

ending June 30 of the reporting year.

EQUIPMENT

[(Purchased gas + produced gas)

OPERATIONS

minus (customer use + company use + appropriate adjustments)] divided by (purchased gas + produced gas) equals percent unaccounted for.

OTHER

NUMBER OF KNOWN SYSTEM LEAKS AT END OF YEAR SCHEDULED FOR REPAIR

Input for year ending 6/30 %.

PART F - ADDITIONAL INFORMATION

PART G - PREPARER AND AUTHORIZED SIGNATURE

(type or print) Preparer’s Name and Title Area Code and Telephone Number Preparer’s email address Area Code and Facsimile Number Name and Title of Person Signing Area Code and Telephone Number Authorized Signature

Form PHMSA F 7100.1-1 (12-05)