14 A.A.C. 5, Exhibit A (Form MM-04)
Form MM-04 - Annual Report for Small Operators of Gas Distribution System
WILL NOT BE DELIVERED WITHOUT PROPER POSTAGE#
ARIZONA CORPORATION COMMISSION#
OFFICE OF PIPELINE SAFETY - GAS SAFETY PROGRAM 1300 WEST WASHINGTON STREET, SUITE 220#
PHOENIX, ARIZONA 85007#
fold here#
fold here#
June 30, 2024 Supp. 24-2 Page 33#
Exhibit A.#
Form MM-04#
ARIZONA CORPORATION COMMISSION PIPELINE SAFETY#
TO BE FILED FOR EACH CALENDAR YEAR, DUE BETWEEN JANUARY 1 AND APRIL 15 OF THE FOLLOWING CALENDAR YEAR#
ANNUAL REPORT FOR CALENDAR YEAR#
SMALL OPERATORS OF GAS DISTRIBUTION SYSTEM#
FACILITY INFORMATION#
OQPERATOR/OWNER#
NAME OF FACILITY#
NAME#
ADDRESS OF FACILITY#
ADDRESS#
CITY#
COUNTY#
CITY#
STATE#
ZIP CODE#
STATE#
ZIP CODE#
FACILITY E-MAIL ADDRESS#
OPERATOR E-MAIL ADDRESS#
AREA CODE#
TELEPHONE#
AREA CODE#
TELEPHONE#
FACILITY TYPE: MHP APT/CONDO SCHOOL BUSINESS # OF BLDG#
FOR UNDERGROUND STEEL SYSTEMS#
SYSTEM INFORMATION#
FEET OF#
DATE OF LAST C/P CHECK IN CAL. YR#
PIPE#
Xf _____#
/#
/#
UNDERGROUND STEEL PIPE#
(If no tests were conducted in, please write "None Conducted")#
ABOVEGROUND STEEL PIPE#
DATE OF LEAK SURVEY CONDUCTED#
IN CAL. YR.#
UNDERGROUND PE PLASTIC PIPE#
/#
/#
(if no tests were conducted in, please write "None Conducted")#
UNDERGROUND PVC PLASTIC PIPE#
TOTAL LEAKS IN SYSTEM#
DURING LAST CAL. YEAR#
TOTAL FEET OF PIPE IN SYSTEM#
CAUSE:#
CORROSION#
NOTE: (if you have any comments or concerns, please note in this box)#
THIRD PARTY DAMAGE#
CONSTRUCTION DEFECT#
MATERIAL DEFECT#
OTHER#
NUMBER OF KNOWN LEAKS#
AT END OF YEAR#
PREPARED BY (TYPE OR PRINT)#
AREA CODE#
TELEPHONE#
NAME AND TITLE PERSON SIGNING#
AUTHORIZED SIGNATURE#
MAIL TO: 1300 W. Washington St., Suite 220, Phoenix, Arizona 85007#
FAX TO: (602) 262-5620 -OR EMAIL TO: safety@azcc.gov#
Arizona Administrative Code 14 A.A.C. 5#
Historical Note#
Exhibit A made by final rulemaking at 20 A.A.R. 75, effective December 16, 2013 (Supp. 13-4). Amended by final rulemaking at 30 A.A.R. 1085 (May 24, 2024), with an immediate effective date of May 2, 2024 (Supp. 24-2).#
June 30, 2024 Supp. 24-2 Page 35#