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Form Phmsa F 7100.1-2 - Mechanical Fitting Failure Report Form For Distribution Operators

NOTICE: This report is required by 49 CFR Part 192.1009. 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



MECHANICAL FITTING FAILURE REPORT FORM

INITIAL REPORT

U.S. Department of Transportation



FOR CALENDAR YEAR 20___

SUPPLEMENTAL REPORT

Pipeline and Hazardous Materials

Safety Administration

FOR DISTRIBUTION OPERATORS

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 1 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. HEADQUARTERS NAME & ADDRESS

2. OPERATOR'S 5 DIGIT IDENTIFICATION NUMBER

Number and Street

City and County

State and Zip Code

PART B - PREPARER AND AUTHORIZED SIGNATURE

(Type or print) Preparer’s Name and Title

Area Code and Telephone Number