FRA F 6180.110 Hazardous Materials Violation Report Form

OMB No. 2130-0509
U.S. Department of Transportation
Federal Railroad Administration

Hazardous Materials Violation Report Form

RR/Co
Code:

1. Respondent:

2. Name of Inspector:

3. Address of Respondent:

6. Location Where the
Violation was Observed:

GSA Codes:

City:

ID No.:

4. Violation Report Number:

5. F6180.96 Report Number - Date:

7. Date Violation Occurred:

8. Train Designation:

Month

Day

Year

State:

9. Line Item No. / Primary Section Violated / Number of
Claims:
Line Item _____

_______._______._______

( ____ claim(s))

10. Violation Narrative:

11. Date Report Prepared:

12. Signature of Inspector(s):

13. Respondent Notification:
Name:
Title:
Date:
Time:

Public reporting burden for this information collection is estimated to average 4 hours per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. According to the Paperwork Reduction Act of 1995, 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 unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 2130-0509. All responses to this
collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection, including suggestions for reducing this burden
to: Information Collection Officer, Federal Railroad Administration, 1120 Vermont Ave., N.W., Washington, D.C. 20590.

Form FRA F6180.110

(9/04)

OMB approval expires 11/30/2006