Form PHMSA Form F-8100. PHMSA Form F-8100. Gas Transmission Integrity Management Program Reporting

U.S. Department of Transportation

Pipeline and Hazardous Materials

Safety Administration

Gas Transmission Integrity Management Program Reporting Form

Form Approval OMB No.2137-0610

Report Date

No.

(DOT Use Only)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 2137-0610. The filling out of this information is mandatory and will take approximately 6 hours to complete.

INSTRUCTIONS

Important: Please read the separate instructions for completing this on-line information template 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.

GENERAL REPORT INFORMATION

Date: _________________________________

Period Ending: _________________________

OPERATOR INFORMATION

Operator ID: \ __ \ __ \ __ \ __ \ __ \

Operator Name: ______________________________________________________________

RELATED OPERATORS INCLUDED IN THE PLAN

Operator ID	Operator ID	Operator ID	Operator ID
\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \
\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \
\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \
\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \	\ __ \ __ \ __ \ __ \ __ \

PERFORMANCE METRICS

 I have not identified any HCAs.

 I have identified HCAs.

Number of total miles (system), should match miles on annual report: ______________________

Number of total miles of pipelines inspected: ______________________

Number of High Consequence Area (HCA) miles in the IMP program: ______________________

Data for Baseline Assessments Only

Number of HCA miles inspected via IMP Baseline assessments (physical pipe miles): ______________________

Number of immediate repairs completed in HCA as a result of IMP Baseline assessments : ______________________

Number of scheduled repairs completed in HCA as a result of IMP Baseline assessments: ______________________

Data for REassessments Only

Number of HCA miles inspected via IMP reassessments (physical pipe miles): ______________________

Number of immediate repairs completed in HCA as a result of IMP reassessments : ______________________

Number of scheduled repairs completed in HCA as a result of IMP reassessments: ______________________

PHMSA Form F-8100.1 Page 1

	LEAKS	FAILURES	INCIDENTS
External corrosion	_________________	_________________	_________________
Internal corrosion	_________________	_________________	_________________
Stress corrosion cracking	_________________	_________________	_________________
Manufacturing	_________________	_________________	_________________
Construction	_________________	_________________	_________________
Equipment	_________________	_________________	_________________
Third party damage	_________________	_________________	_________________
Incorrect operations	_________________	_________________	_________________
Weather related and outside forces	_________________	_________________	_________________

PREPARER AND AUTHORIZED SIGNATURE
(type or print) Preparer's Name and Title
Preparer's E-mail Address			Area Code and Telephone Number
Authorized Signature (type or print) Name and Title		Date	Area Code and Telephone Number
SENIOR EXECUTIVE OFFICER’S SIGNATURE CERTIFYING INFORMATION AS REQUIRED BY 49 U.S.C. 60109(F)
(type or print) Name and Title
E-mail Address			Area Code and Telephone Number
Signature		Date
PHMSA Form F-8100.1 Page 2