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 _____
|
SKETCH SHOWING LEAK/S
LOCATED |
METER SET |
|
|
Meter
No. ___________ (if inspected) |
LEAK DATA
|
Detected By |
|
Collecting |
|
Probable Source |
|
C.G.I. Test |
|
|
CGI
Meter/ Bar Hole |
|
In
Building |
|
Mainline |
|
Gas
Percent (%) |
|
|
Odor |
|
Near
Building |
|
Service
Line |
|
L.E.L. |
|
|
Flame
Pack |
|
In
Manhole |
|
Tank/s |
|
|
|
|
Visual/Vegetation |
|
In
Soil |
|
Valve |
|
|
|
|
Other |
|
In
Air |
|
Meter
Set |
|
|
|
|
|
|
Other |
|
Service
Tap |
|
|
|
|
Pressure at leak |
|
Surface |
|
Leak Course |
|
|
Tank
pressure |
|
Lawn |
|
Corrosion |
|
|
1st
stage piping pressure |
|
Soil |
|
Outside
Force |
|
|
2nd
stage piping pressure |
|
Paved |
|
Construction
Defect |
|
|
|
|
Other |
|
Material
Failure |
|
|
|
|
|
|
Other |
|
|
Component |
Explanation |
Part of System |
|
Material Type |
Size |
Year Installed |
|
Pipe |
|
Main |
|
Steel |
|
|
|
Valve |
|
Service |
|
Plastic |
|
|
|
Fitting |
|
Meter
Set |
|
Copper |
|
|
|
Regulator |
|
Customer
Piping |
|
Other |
|
|
|
Other |
|
Tank/s |
|
|
|
|
|
|
|
Other |
|
|
|
|
|
|
|
|
|
|
|
|
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):