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

- **operation:** document
- **citation:** CPUC GO 112-F Appendix B
- **title:** CPUC General Order 112-F Appendix B - Report of Gas Leak or Interruption
- **source type:** regulation
- **agency:** California Public Utilities Commission
- **status:** current
- **official:** true
- **published on:** 2015-06-25
- **effective on:** 2015-06-25
- **summary:** 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
Pho
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- **app url:** https://regulus.evalyn.ai/document/ca-cpuc-go-112-f-appendix-b
- **source url:** https://docs.cpuc.ca.gov/PublishedDocs/Published/G000/M163/K327/163327660.PDF
**body:**

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).
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