# Form MM-04 - Annual Report for Small Operators of Gas Distribution System

- **operation:** document
- **citation:** 14 A.A.C. 5, Exhibit A (Form MM-04)
- **title:** Form MM-04 - Annual Report for Small Operators of Gas Distribution System
- **source type:** regulation
- **agency:** Arizona Corporation Commission
- **status:** current
- **official:** true
- **published on:** 2024-06-30
- **effective on:** 2024-05-02
- **summary:** 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 
- **machine formats:** - **json:** https://regulus.evalyn.ai/document/az-aac-14-5-exhibit-a-mm-04.json
- **markdown:** https://regulus.evalyn.ai/document/az-aac-14-5-exhibit-a-mm-04.md
- **app url:** https://regulus.evalyn.ai/document/az-aac-14-5-exhibit-a-mm-04
- **source url:** https://apps.azsos.gov/public_services/Title_14/14-05.pdf
**body:**

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
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- **body characters:** 2001