COMPANY: __
This form is to be completed
each time an LP gas line is uncovered for inspection or any other reason, such
as making service connections, main extensions, replacements, etc.
DATE: ________________________
01. Location: __
02. Name of Inspector:
__
03. Designation: Tank Main Service _________
04. Age of Pipe/Tank: Years
Line/Tank Size: inches/gals. __
05. Maximum Operating Pressure: __
06. Pipe Specification: Steel Plastic
Copper __
07. Cathodic Protection Tank/Line: Yes No
08. Coating: Yes No _____
09. External Condition:
Smooth Pitted Depth of Pits
10. Internal Condition: Smooth
Pitted Depth of Pits
Name any existing conditions
that could cause harm to the LP gas system.
________________________________________________________________________________
Corrective Measures Taken if
Needed:
__
__
Anodes Installed: How many? Size Location __
Soil conditions surrounding
tank/pipe: __
LP Gas System Leak Survey Report
COMPANY: ___
Receipt of Report: ___
Date: Time: ___
Location of Leak: ___
(address,
intersection, etc.)
Reported by: ___
___
(Name) (Address)
Description of Leak: ___
(inside/outside)
Leak Detected by: ___
Leak Reported by: ___
Report Received by: ___
Dispatched
Date: Time:
___
Investigation Assigned
to: ___
(Name)
Assigned as Immediate Action
Required? Yes No __________
Investigation
Date: Time:
____
Investigation by: Leak Found? Yes
__ No ____
CGI Used? Yes No Leak Grade: 1 2 3
Location of Leak: ____
Cause of Leak: ____
Condition Made Safe: Date: Time: ____
Repair
See form 3
COMPANY: Grade of Leak
ADDRESS: Grade I _____
Grade II _____
______________________________________________ Grade III _____
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SKETCH SHOWING LEAK/S
LOCATED |
METER SET |
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Meter
No. ___________ (if inspected) |
LEAK DATA
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Detected By |
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Collecting |
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Probable Source |
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C.G.I. Test |
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CGI
Meter/ Bar Hole |
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In
Building |
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Mainline |
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Gas
Percent (%) |
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Odor |
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Near
Building |
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Service
Line |
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L.E.L. |
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Flame
Pack |
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In
Manhole |
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Tank/s |
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Visual/Vegetation |
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In
Soil |
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Valve |
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Other |
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In
Air |
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Meter
Set |
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Other |
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Service
Tap |
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Pressure at leak |
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Surface |
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Leak Course |
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Tank
pressure |
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Lawn |
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Corrosion |
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1st
stage piping pressure |
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Soil |
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Outside
Force |
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2nd
stage piping pressure |
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Paved |
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Construction
Defect |
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Other |
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Material
Failure |
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Other |
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Component |
Explanation |
Part of System |
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Material Type |
Size |
Year Installed |
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Pipe |
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Main |
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Steel |
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Valve |
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Service |
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Plastic |
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Fitting |
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Meter
Set |
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Copper |
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Regulator |
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Customer
Piping |
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Other |
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Other |
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Tank/s |
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Other |
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Pipe/Tank/s Condition: Good:
Fair: Poor:
Coating Condition: Good: Fair: Poor:
Date Repaired: Date
Rechecked: ________________
Remarks: ________________
Signed: ________________
An LP gas system must be patrolled where anticipated physical damage might occur on the system resulting in failure or leakage to that portion of the system. Extreme weather conditions might cause conditions on systems that would require patrolling.
Frequency: When patrolling
is required then the frequency of the patrol is as often as necessary, but no
less than :
Business district;
4 times each calendar year, not exceeding intervals of 4½ months.
Outside business district; 2 times each calendar year, not exceeding intervals of 7½ months.
COMPANY:
Period Covered: Began:
Ended:
Areas Covered:
Map References:
Leakage Indications
Discovered (describe locations and indications, such as a condition of
vegetation):
Describe any unusual
conditions and their locations in the system:
Other Factors noted which
could affect present or future safety or operations of the gas system:
Follow-up (repairs,
maintenance or test resulting from this inspection):
Comments:
Signature of person in
charge of patrol: ______
Date:
COMPANY:
Location:
Regulator # 1
Make: Model:
Size: Orifice Size:
Pressure at inlet: Pressure
at outlet:
M.A.O.P. of System to which
it is connected:
Regulator # 2
Make: Model:
Size: Orifice Size:
Pressure at inlet: Pressure at outlet: ______
M.A.O.P. of System to which
it is connected:
Regulator # 3
Make: Model:
Size: Orifice Size:
Pressure at inlet: Pressure at outlet: ______
M.A.O.P. of System to which
it is connected:
Does regulator have an
internal relief valve? Yes____________
No ____________
Was regulator checked for
lock up? Yes____________
No ____________
Is regulator protected
against damage from outside forces? Yes____________
No ____________
Was vent and screen checked
for blockage? Yes____________
No ____________
Signature:
Date:
COMPANY:
Location:
Relief Valve Information
Make: Type:
Size: Orifice Size:
Type of Loading:
Spring: Pilot: Other:
Range:
Pressure Setting:
Connecting Pipe Size:
Vent Stack Size:
Capacity:
General Condition of:
Relief Valve:
Support Piping:
Weather Protection:
General Area:
Repairs Required:
Repairs Made:
Remarks:
Inspector:
Signature: Date:
Frequency: - annually
System: Name: ______
Location:
Number of Valves: __________
Location
/Type / Use Results / Actions
____________
____________
____________
____________
____________
____________
General Comments: ______
Signed:_____________________________
Prepared By: Date Prepared: ______
System: Name:
Location:
(System map showing tanks,
mains and service lines with tank and pipe sizes and distances, key valve
locations, cathodic protection system, regulators and pressures and other
utility lines.)
Frequency: At a minimum, each time LP gas is delivered to an operator’s plant or when LP gas by-passes the plant. Note: In large systems it may be necessary to use instrumentation to verify the odorant at certain locations of the system.
System: Name
________________________________________________________________
Location: _____________________________________________________________________
Test Point:
____________________________________________________________________
Date: ________________ Time: ________________
Test Person: _________________
Odor Level: Nil: _____ Barely Detectable: _____ Readily Detectable: _____ Strong: _____
Test Point:
____________________________________________________________________
Date: ________________ Time: ________________ Test Person: ________________
Odor Level: Nil:
_____ Barely Detectable: _____
Readily Detectable: _____ Strong: ____
Test Point:
Date: Time:
Test Person:
Odor Level: Nil: Barely
Detectable: Readily Detectable: Strong:
Remarks:
Signed:
Telephonic Report of Customer Leak
COMPANY:
Customer Leak Information
Time Call Received: a.m./p.m. Date:
Name of Caller: Caller’s Phone Number:
Name of Customer if not
Caller:
Address of Leak: ____
____
____
Nature of Complaint: Odor (
) Blowing Gas ( )
Dead Vegetation ( )
Other (describe):
__________________________________________________________
Is the gas odor or sound
inside the residence? Yes No
If so, where is it located?
(at the water heater, at the heating system, at the stove, in the hall, in the
kitchen, etc.):
Is the gas odor or sound
outside the residence? Yes __ No ____
If so, where is it located?
(at the meter, near the street, at the house, at the tank/s, at the pool, at
the gas grill, etc.):
How long have you been
smelling or hearing the gas?
Will someone be home for us
to check the leak? Yes __ No ____
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Leak Response Information
Time Dispatched
Investigator: am/p.m. Date:
Name of Investigator:
Time of Investigator’s
Arrival at Scene of Leak: a.m./p.m.
Action Taken:
Time of Investigator
Completion at Scene of Leak: a.m./p.m.
Additional Follow-up (if
needed): Yes ___
No ____
If so, what type of
follow-up:
Additional Remarks:
Signature of Investigator:
Signature of Supervisor:
Frequency: A minimum of every three years although it is recommended to inspect the system for atmospheric corrosion annually during other annual inspection requirements.
System:
Name_________________________________________________________________
Location:
_____________________________________________________________________
Type of Structure: Tank / size and age: ____________ Main / size and age: ______________
Service / size and age:
_________________ Operating
Pressure: __________________
Condition of paint and
surface of:
Tanks:
Piping:
Meters:
Fittings:
Vaporizers:
Other:
Corrective Measures to be
taken:
Signed:
___________________________
Dated:
____________________________
Frequency: Annually
System Name:
_________________________________________________________________
Surveyed By:
________________________ Date
Surveyed: _________________________
Starting Location of Survey:
______________________________________________________
Ending Location of Survey:
_______________________________________________________
Underground Tank/s : Yes ___________ No ___________
Readings Around Tank(s)
Remote From Anodes:
Reading #3 ________________
Reading #4 ________________
Take copper sulfate
half-cell readings at approximately 20 foot intervals along the mains and
service lines.
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FT |
RDG |
FT |
RDG |
FT |
RDG |
FT |
RDG |
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Signed: Date:
Corrosion
Control – Rectifier Inspection
COMPANY:
__________________________________________________________________
LOCATION:
__________________________________________________________________
BRAND OF RECTIFIER:
_______________________________________________________
RECTIFIER SERIAL
NUMBER:
_________________________________________________
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Date |
Supply Voltage |
Output Volts |
Output Amps |
Rectifier Condition |
Remarks |
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Signature: Date: _____
OPERATING COMPANY:
Testing Company:
This form must be completed for each section of newly installed section of pipe or service line and on each service line that is disconnected from the main for any reason.
Test Data
Type of Pipe:
Size of Pipe: inches Length
of Line:
Location of Line:
Tested with: Nitrogen ( ) Air ( )
Propane Vapor ( )
Water ( )
Other (describe):
Time Started: a.m./p.m. Time
Ended: ________________ a.m./p.m.
Test Pressure Start: psig
Test Pressure Stop: psig
Line Loss noted? : Yes No
_____________
Reason for Line Loss:
Corrective Measures
Taken:
Remarks:
Company Representative:
Signature: Date: