CPUC General Order 112-F Appendix B - Report of Gas Leak or Interruption

CALIFORNIA PUBLIC UTILITIES COMMISSION#

Report of Gas Leak or Interruption*#

CPUC File No. 420#

Part I: CPUC CONTACT INFORMATION#

Operator: | | CPUC Contact: Name | | Recorder | FAX Contact Person | | | Date | | Time: (24hr) | | CPUC Information Request: Written Report | Sketch/Photo | FD Report Phone: | | DOT Notified - Yes No | DOT Report Number: |#

Part II: INCIDENT DETAILS#

Incident Location | Incident Time | Reported to the Operator City/County: | | Date | | Date: | | Time: (24hr) | Address/Location: | | Time: (24hr) | | Reported by: | Reason(s) for Reporting (check all that apply) Gas leak associated with: | Emergency action required: Death | Injury | $$Damage | Media Coverage | Traffic Rerouted | Area Blocked Off | Building Evacuated Service Interruption | Operator Judgment | Other Emergency actions (describe) | Transmission Line Test Failure | Required Transmission Line Shutdown | Incident Cause | Dig In | Fire/Explosion | Construction Defect | Material Failure | Corrosion | Vehicle Impact | Suicide UNKNOWN - MORE INFORMATION TO FOLLOW | Other (describe) | Escaping Gas Involvement (check all that apply) | | Leak Only | Fire | Explosion | None Summary (Briefly describe the incident and the probable cause.) | Gas Equipment Affected (check all that apply) | Specification of Failed Equipment | Injuries and Fatalities Main | Regulator | Meter | Valve | Material | Steel | Cast Iron | | None | Service Line | Controls | Service Riser | Plastic | Copper | | Injuries | Fatalities Customer Facility | Transmission Line | Other | | Company: | | Other (describe) | | Pipe Size MAOP | Operating Pressure | Other: | | Dig In Information | Estimated Damage USA notification required: Yes No | Name of Excavator: | | Damage to gas facilities: | USA notified: Yes No | Excavator Contact Person: | | Other damage involving gas: | Facilities properly marked: Yes No | Phone: | | Total: | Recovery from Incident | Public Agencies on Scene | Customer Outage | | Date | Time (24hr) | | Co Personnel on Scene | | | Media | Police | Customers out of service | | Gas flow stopped | | | Fire | Ambulance | Customer-hours outage | | Service restored | | |#

Part III: CPUC INVESTIGATION#

Is further investigation warranted? Yes No | Signature of CPUC Engineer | | Date incident investigated: | | Field report attached? Yes No | CPUC Inspector: | |#

*The information contained in this report is provided solely for the confidential use of the Commission and its staff and is not open to public inspection (PUC GO 66-C, Public Utilities Code, Sections 315 and 583).#