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pdfOMB NO: 2137‐0604
EXPIRATION DATE: mm/dd/yyyy
Public Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be
subject to a penalty for failure to comply with a collection of information subject to the requirements of the
Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The
OMB Control Number for this information collection is 2137‐0604. Public reporting for this collection of
information is estimated to be approximately (60) minutes per response, including the time for reviewing
instructions, gathering the data needed, and completing and reviewing the collection of information. All responses
to this collection of information are (mandatory or voluntary). Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to: Information
Collection Clearance Officer, PHMSA, Office of Pipeline Safety (PHP‐30) 1200 New Jersey Avenue SE, Washington,
D.C. 20590.
OPS Integrity Management Database
New Notification Form
Operator:
Submitted by:
Job Title:
Contact Email:
Contact Phone:
Date Submitted:
Type: (at least one must be checked)
Repair
Technology
Interval
Long‐Term Pressure Reduction
Biofuels
Summary: Brief summary statement describing the purpose of the notification:
Commodity:
Size:
Material:
Weld Type:
Coatings:
Design Pressure:
MOP:
Wall Thickness:
Date Last Pigged:
Pigging Report:
Year Manufactured:
Year Installed:
Last Hydro:
Date last hydro was
performed.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form – General Section
1
Additional Pipeline Details: Provide any additional details about the affected pipeline.
Segment Location: Information about location of affected segment(s), such as milepost, country, state, etc. (report for each affected
segment.) Instead you may enter “Entire System” if applicable.
Segment Details: Enter any additional information describing the affected segment(s).
Must check one:
Affected States:
HCA Miles: Length of segment that “can
affect” HCA
Interstate Pipeline
Intrastate Pipeline
Type of HCA Affected: (Can be more than one)
High Population Area
Ecological USA (If checked, also enter
Drinking Water USA
the Resources Affected below)
Other Populated Area
Navigable waters
HCA Interaction: Describe the nature of HCA interaction (intersects, release can affect, etc.
Use one of the following five forms, as appropriate.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form – General Section
2
Notification Form – Repair Section
Category: (at least one must be checked)
Immediate
60‐day
180‐day
Defects: Provide a description of defects requiring repair. Be sure to indicate whether multiple and/or clustered defects exist. Characterize
any defects that have been excavated.
Repairs Required: Provide a description of the repairs needed
Reason for Delay: Describe factors within and outside of operator’s control.
Pressure Reason: Explain why pressure cannot be reduced. Justify adequate safety for the operating period expected.
Safety Basis: Basis for concluding delay will not jeopardize public safety or environmental protection.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form – Repair Section
3
Schedule: Proposed schedule for repair.
Mitigation: Describe other mitigative actions planned.
Other info: Other information relevant for PHMSA review. If additional supporting material has been forwarded by email, provide a brief
description below.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form – Repair Section
4
Notification Form – Technology Section
Assessment Schedule: Scheduled date of assessment.
Description: Description of other technology to be used.
Equivalency Basis: Basis for concluding the “equivalent understanding” of pipe condition will be provided.
Other Info: Other information relevant for PHMSA review. If additional supporting material has been forwarded by email, provide a brief
description below.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form – Technology Section
5
Notification Form – Interval Section
Basis Type: (at least one type must be checked)
Engineering Basis
Unavailable Technology
Last Assessment: Provide both the date of the last assessment and the method
New Interval: Proposed new interval (applies only to engineering basis).
Schedule: Proposed schedule for completion (applies only to unavailable technology).
Additional Actions: Actions to provide equivalent understanding (engineering basis), or interim evaluation of pipeline integrity
(unavailable technology) .
Basis: Summary of engineering basis for extended interval, or reason why required interval cannot be met.
Other Info: Other information relevant for PHMSA review. If additional supporting material has been forwarded by email, provide a brief
description below.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form –Interval Section
6
Notification Form – Long‐Term Pressure Reduction Section
Reason for Delay: Describe factors within and outside of operator’s control.
Remedial Actions: Describe further remedial actions planned or taken.
Other Info: Other information relevant for PHMSA review. If additional supporting material has been forwarded by email, provide a brief
description below.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form –Long Term Pressure Reduction Section
7
Notification Form – Biofuels Section
Notification Sub‐Type : (eg. Batch Test, Commercial Movement, etc.)
Biofuels Info: Describe further info related to Biofuels.
Other Info: Other information relevant for PHMSA review. If additional supporting material has been forwarded by email, provide a brief
description below.
Notification Sub‐Type : (eg. Batch Test, Commercial Movement, etc.)
Biofuels Info: Describe further info related to Biofuels.
Other Info: Other information relevant for PHMSA review. If additional supporting material has been forwarded by email, provide a brief
description below.
Hazardous Liquid IMP Notifications Form PHMSA F‐1001.1
New Notification Form – Biofuels Section
8
| File Type | application/pdf |
| File Title | Microsoft Word - Notification Form.docx |
| Author | Lisa |
| File Modified | 2010-07-20 |
| File Created | 2010-07-16 |