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U.S. Department of Transportation
Office of Hazardous Materials Enforcement
1200 New Jersey Ave.SE
Washington, DC 20590

Pipeline and Hazardous
Materials Safety Administration

SISP EXIT BRIEFING

Date:

Report Control #:

Company Name:

Address:

Company Web Address:

NAME OF INDIVIDUALS RECEIVING BRIEFING:

Name:

Title:

E-mail:

Name:

Title:

E-mail:

Name:

Title:

This has been a Systems Integrity Safety Program (SISP) review conducted in accordance with the SISP Agreement. This exit briefing addresses probable violations and makes recommendations on business practices.

During the review the following probable violations of 49 CFR and/or quality assurance recommendations were noted:

Section:

Explanation:

Recommendations:

Section:

Explanation:

Recommendations:

Section:

Explanation:

Recommendations:

Section:

Explanation:

Recommendations:

Section:

Explanation:

Recommendations:

Quality Assurance Items:

Explanation:

Example:

Recommendations

Explanation:

Example:

Recommendations

Explanation:

Example:

Recommendations

Explanation:

Example:

Recommendations

The information gathered during this SISP Review and any issues noted were discussed with the company representative prior to departing the facility. Documentation of the corrective action addressing the probable violation(s) discussed during the SISP Exit Briefing must be provided within ten (10) working days. Documentation addressing quality assurance items should be provided to the Investigator prior to the Final Recommendations Report.

I certify that I received the above briefing as it appears on this form. By signing this form I acknowledge that I have reviewed it and have received a copy.

Signature of Investigator(s)

Date

Signature of Representative(s)

Date