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pdfNOTICE: This report is required by 49 CFR Part 191. Failure to report may result in a civil penalty
as provided in 49 USC 60122.
OMB No. 2137-0522
Expiration Date MM/DD/YYYY
U.S. Department of Transportation
ANNUAL REPORT FOR CALENDAR YEAR 20___
Pipeline and Hazardous Materials
SMALL LIQUEFIED PETROLEUM GAS SYSTEMS
DOT USE ONLY
Initial Date
Submitted
Report
Submission Type
Date Submitted
Safety Administration
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 2137-0522. Public
reporting for this collection of information is estimated to be approximately 6 hours 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. 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.
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 PHMSA Pipeline Safety Community Web Page at
http://www.phmsa.dot.gov/pipeline/library/forms.
PART A - OPERATOR INFORMATION
DOT USE ONLY
1. OPERATOR’S 5 DIGIT IDENTIFICATION NUMBER (OPID)
2. NAME OF OPERATOR:
/
/
/
/
/
/
3. RESERVED
4. HEADQUARTERS ADDRESS:
Street Address
State: /
/
/ Zip Code: /
5. STATE IN WHICH SMALL LIQUEFIED PETROLEUM GAS (LPG) SYSTEM OPERATES:/
state in which system operates)
Form PHMSA F 7100.1-2 (rev M YYYY)
/
/
/
/
/
/ - /
/
/
/
/
/ (provide a separate report for each
Reproduction of this form is permitted.
Page 1 of 2
NOTICE: This report is required by 49 CFR Part 191. Failure to report may result in a civil penalty
as provided in 49 USC 60122.
OMB No. 2137-0522
Expiration Date MM/DD/YYYY
PART B – NUMBER AND MILEAGE OF SYSTEMS and NUMBER AND STATUS OF LEAKS
CUSTOMERS
Number of LPG Systems
1-25
26-49
50-74
75-99
TOTAL
Calc
Mileage of LPG Systems
Calc
Number of Leaks Identified
Calc
Number of Leaks Repaired
Calc
Number of Unrepaired Leaks
Calc
Form PHMSA F 7100.1-2 (rev M YYYY)
Reproduction of this form is permitted.
Page 2 of 3
NOTICE: This report is required by 49 CFR Part 191. Failure to report may result in a civil penalty
as provided in 49 USC 60122.
OMB No. 2137-0522
Expiration Date MM/DD/YYYY
PART C - PREPARER SIGNATURE
/__/__/__/-/__/__/__/-/__/__/__/__/
Telephone Number
Preparer's Name(type or print)
Preparer's Title
Preparer's E-mail Address
Form PHMSA F 7100.1-2 (rev M YYYY)
Reproduction of this form is permitted.
Page 3 of 3
| File Type | application/pdf |
| File Title | Microsoft Word - Small LPG Annual Report Proposal Gas Distribution NPRM 8.23.23.docx |
| Author | Angela.Hill |
| File Modified | 2023-09-15 |
| File Created | 2023-09-15 |