Form Phmsa F 7100 1 1 PDF Details

Have you ever wondered what it takes to be a hazmat driver? In order to transport hazardous materials, drivers need to have the proper certification. The Form Phmsa F 7100 1 1 is an application for hazmat drivers seeking certification. This form must be filled out and submitted to theFederal Motor Carrier Safety Administration (FMCSA). In order to help applicants understand this process, we will provide a brief overview of the Form Phmsa F 7100 1 1. Keep reading below for more information on theForm Phmsa F 7100 1 1!

QuestionAnswer
Form NameForm Phmsa F 7100 1 1
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesGas Distr Annual Form PHMSA F 7100.1 1 (01 2011) phmsa form 71001

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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

OMB No. 2137-0522

each violation for each day the violation continues up to a maximum of $1,000,000 as provided in 49 USC 60122.

Expiration Date 01/31/2014

 

 

 

U.S. Department of Transportation

Pipeline and Hazardous Materials

Safety Administration

ANNUAL REPORT FOR CALENDAR YEAR 20___

INITIAL REPORT

GAS DISTRIBUTION SYSTEM

SUPPLEMENTAL REPORT

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 16 hours per submission, 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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART A - OPERATOR INFORMATION

 

 

 

 

 

 

 

DOT USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

NAME OF OPERATOR

 

 

 

 

 

3. OPERATOR'S 5 DIGIT IDENTIFICATION NUMBER

 

 

 

 

 

 

 

 

/

/

/

 

/

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

LOCATION OF OFFICE WHERE ADDITIONAL

 

 

 

 

4. HEADQUARTERS NAME & ADDRESS, IF DIFFERENT

 

 

 

 

INFORMATION MAY BE OBTAINED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

UNPROTECTED

CATHODICALLY

 

 

PROTECTED

 

 

 

 

 

 

BARE

COATED

BARE

COATED

MILES OF MAIN

PLASTIC

CAST/

WROUGHT

IRON

DUCTILE

IRON

COPPER

OTHER

SYSTEM TOTAL

NO. OF SERVICES

2. MILES OF MAINS IN SYSTEM AT END OF YEAR

 

 

MATERIAL

 

UNKNOWN

 

 

2" OR LESS

 

 

OVER 2"

 

 

OVER 4"

 

 

OVER 8"

 

 

OVER 12"

 

SYSTEM

 

 

 

 

 

 

 

THRU 4"

 

 

THRU 8"

 

 

THRU 12”

 

 

 

TOTALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DUCTILE IRON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COPPER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAST/WROUGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLASTIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. PVC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. PE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. ABS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLASTIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTEM TOTALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. NUMBER OF SERVICES IN SYSTEM AT END OF YEAR

AVERAGE SERVICE LENGTH

 

FEET

Form PHMSA F 7100.1-1 (01/2011)

Reproduction of this form is permitted.

Page 1 of 3

 

 

MATERIAL

UNKNOWN

1" OR LESS

 

OVER 1"

 

OVER 2"

 

OVER 4"

 

OVER 8"

 

 

TOTAL

 

 

 

 

THRU 2"

 

THRU 4"

 

THRU 8”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STEEL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DUCTILE IRON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COPPER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CAST/WROUGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IRON

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLASTIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. PVC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. PE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. ABS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLASTIC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SYSTEM

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTALS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

UN-

KNOWN

MILES OF MAIN

NUMBER OF

SERVICES

PRE- 1940

1940-

1949

1950- 1960-

1959 1969

1970-

1979

1980- 1990-

1989 1999

2000-

2009

2010-

2019

TOTAL

PART C - TOTAL LEAKS AND HAZARDOUS LEAKS ELIMINATED/REPAIRED DURING YEAR

 

Mains

 

 

Services

CAUSE OF LEAK

Total

Hazardous

Total

Hazardous

CORROSION

NATURAL FORCES

EXCAVATION DAMAGE

OTHER OUTSIDE FORCE DAMAGE

MATERIAL OR WELDS

EQUIPMENT

INCORRECT OPERATIONS

OTHER

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

 

 

PART D – EXCAVATION DAMAGE

 

 

PART E – EXCESS FLOW VALVE (EFV) DATA

 

 

 

Number of Excavation Damages

__________________

 

Total Number Of EFVs on Single-family Residential Services

 

 

 

 

 

 

Installed During Year _________

 

Number of Excavation Tickets

__________________

Estimated Number of EFVs In System At End Of Year _________

Form PHMSA F 7100.1-1 (01/2011)

Reproduction of this form is permitted.

Page 2 of 3

 

 

PART F - TOTAL NUMBER OF LEAKS ON FEDERAL LAND

 

PART G - PERCENT OF UNACCOUNTED FOR GAS

 

 

 

REPAIRED OR SCHEDULED FOR REPAIR

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

ending June 30 of the reporting year.

 

 

 

 

 

 

 

[(Purchased gas + produced gas) minus (customer use +

 

 

 

 

 

 

 

company use + appropriate adjustments)] divided by (purchased

 

 

 

 

 

 

 

 

 

 

 

 

 

 

gas + produced gas) equals percent unaccounted for.

 

 

 

 

 

 

 

Input for year ending 6/30________________________ %.

 

 

 

 

 

 

 

 

 

PART H - ADDITIONAL INFORMATION

PART I - PREPARER AND AUTHORIZED SIGNATURE

(Type or print) Preparer’s Name and Title

Preparer’s email address

Name and Title of Person Signing

Authorized Signature

Area Code and Telephone Number

Area Code and Facsimile Number

Area Code and Telephone Number

Form PHMSA F 7100.1-1 (01/2011)

Reproduction of this form is permitted.

Page 3 of 3