VDPS 7100.1 Incident Report-Gas Distribution System

Report Date: *

Operator's 5 digit Identification number: *

Operator Information

Name of Operator: *

Address: *

Number and Street

City: *

County: *

State: *

Zip Code: *

Location of Incident

Address: *

Number and Street

City: *

County: *

State: *

Zip Code: *

Class Location: *

Incident on Federal Land: *

Time and Date of Incident

Time: *

Date: *

Reason for Reporting

Fatality:

Injury Requiring Inpatient Hospitalization:

Property Damage or Loss: $

Estimate

Other:

Operator judgement/emergency action

Supplemental Report

Elapsed time until area was made safe:

Telephone Report:

Estimated pressure at point and time of incidnet: * (PSIG)

Maximum allowable operating pressure: * (MAOP/PSIG)

MAOP established by

Test pressure: (PSIG)

49 CFR 192.619:

Estimate

Other

Apparent Cause: *

Corrosion (continue in Part A)

Damage by outside forces (continue in Part B)

Construction/operating error (continue in Part C)

Accidentally caused by operator (continue in Parts B or C)

Other

Other Description:

Please describe other cause

Narrative description of factors contributing to the incident: *

Environment

Other description:

Part A Corrosion

Where did the damage incident occur?:

Visual Description:

Localized pitting

General corrosion

Other (please describe)

Other description:

Cause:

Galvanic

Other

Pipe Coating Information:

Bare

Coated

Was corroded part of pipeline considered to be under cathodic protection prior to discovering incident:

If, yes what year was protection started?:

Additional Information:

Part C - Construction Defect

Cause:

Other description:

Additional Information:

Part D - Other

Brief Description:

Vermont Underground Utility Damage Prevention

Department of Public Service