### Office of Pipeline Safety

### Gas Integrity Management (49 CFR Part 192)

### Notification Template

*Enter information only in portions of tables with white background.
This template covers 3 different types of Notifications. Some sections
of this template only apply to specific Notifications types as noted.
Any section that does not apply should be left blank. See following web
page for methods of submitting notifications to OPS:*

[*http://primis.phmsa.dot.gov/gasimp/Notifications.htm*](http://primis.phmsa.dot.gov/gasimp/Notifications.htm)

*In addition to completing this template to notify OPS, operators must
contact individual states for notifications also required to be
submitted to state and local authorities!*

Table 1. Operator Identification and Contacts

+--------+-------------------------+-----------------------------------+
| \[     | Contact Information     | *Complete All Applicable          |
| tblCon |                         | Information*                      |
| tact\] |                         |                                   |
+--------+-------------------------+-----------------------------------+
| \[sbm  | *Date Notification      |                                   |
| Date\] | Submitted*              |                                   |
+--------+-------------------------+-----------------------------------+
| \[opr  | *Operator Name*         |                                   |
| Name\] |                         |                                   |
+--------+-------------------------+-----------------------------------+
| \[o    | *OPS-Assigned Operator  |                                   |
| prID\] | ID*                     |                                   |
+--------+-------------------------+-----------------------------------+
| \[s    | *Affected States-       |                                   |
| ysSttI | Interstate Lines\       |                                   |
| nter\] | *(2-letter state codes, |                                   |
|        | separate by commas)     |                                   |
+--------+-------------------------+-----------------------------------+
| \[s    | *Affected States-       |                                   |
| ysSttI | I                       |                                   |
| ntra\] | n[tra]{.underline}state |                                   |
|        | Lines\                  |                                   |
|        | *(2-letter state codes, |                                   |
|        | separate by commas)     |                                   |
+--------+-------------------------+-----------------------------------+
| \      | *Commodity Transported* |                                   |
| [sysCo |                         |                                   |
| mmod\] |                         |                                   |
+--------+-------------------------+-----------------------------------+
| \[sbm  | *Name of Person         |                                   |
| Name\] | Submitting*             |                                   |
+--------+-------------------------+-----------------------------------+
| \[sbmT | *Submitter\'s Job       |                                   |
| itle\] | Title*                  |                                   |
+--------+-------------------------+-----------------------------------+
| \[sbmE | *Submitter\'s Email     |                                   |
| mail\] | Address*                |                                   |
+--------+-------------------------+-----------------------------------+
| \[sbmP | *Submitter\'s Phone     |                                   |
| hone\] | Number*                 |                                   |
+--------+-------------------------+-----------------------------------+
| \[mgr  | *Name of Responsible    |                                   |
| Name\] | Manager*                |                                   |
|        |                         |                                   |
|        | (if not person          |                                   |
|        | submitting)             |                                   |
+--------+-------------------------+-----------------------------------+
| \[mgrT | *Manager\'s Job Title*  |                                   |
| itle\] |                         |                                   |
+--------+-------------------------+-----------------------------------+
| \[mgrE | *Manger\'s Email        |                                   |
| mail\] | Address*                |                                   |
+--------+-------------------------+-----------------------------------+

Table 2. Brief Summary Statement

  ------------- ----------------------------------------------------------------
  \[tblSum\]    *Provide a brief summary statement below describing the purpose
                of the notification.*

  \[sumText\]   
  ------------- ----------------------------------------------------------------

Table 3. Selection of Notification Type

  ------------- ---------------------------------------------------- -------------
  \[tblType\]   Type of Notification                                 *Type an
                                                                     **X** in the\
                                                                     Appropriate
                                                                     Cell*

  \[type_1\]    ***Type 1**. Substantial Change to IM Program. (¶    
                192.909(b))*                                         

  \[type_2\]    ***Type 2.** Other Assessment Technology. (¶         
                192.921(a)(4) or 192.937(c)(4))*                     

  \[type_3\]    ***Type 3.** Schedule for Evaluation and             
                Remediation. (¶ 192.933(c))*                         
  ------------- ---------------------------------------------------- -------------

*NOTE: The choice of notification type affects the applicability of
other tables below.*

Table 4. Description of IM Program Change (Type 1 Notifications Only)

  ------------- ----------------------------------------------------------------
  \[tblPgm\]    *For Type 1 notifications, provide a description of the
                substantive changes and their effect on the IM program.*

  \[pgmText\]   
  ------------- ----------------------------------------------------------------

*NOTE: Leave this table blank except for Type 1 notifications.*

Table 5. Justification for Use of Other Assessment Technology (Type 2
Notifications Only)

+-------+------------------------+-------------------------------------+
| \     | Technology Information | *Complete All Applicable            |
| [tblT |                        | Information*                        |
| ech\] |                        |                                     |
+-------+------------------------+-------------------------------------+
| \     | *Assessment Schedule   |                                     |
| [tech | Date*                  |                                     |
| Sch\] |                        |                                     |
+-------+------------------------+-------------------------------------+
| \[    | *Description of Other  |                                     |
| techD | Technology to be Used* |                                     |
| esc\] |                        |                                     |
|       | (Include references to |                                     |
|       | standards, where       |                                     |
|       | appropriate)           |                                     |
+-------+------------------------+-------------------------------------+
| \[t   | *Basis for Concluding  |                                     |
| echBa | that \"Equivalent      |                                     |
| sis\] | Understanding\" of     |                                     |
|       | Pipe Condition will be |                                     |
|       | Provided*              |                                     |
+-------+------------------------+-------------------------------------+

*NOTE: Leave this table blank except for Type 2 notifications.*

Table 6. Evaluation and Remediation Details (Type 3 Notifications Only)

+-------+-----------------------+-------------------------------------+
| \[tbl | Remediation           | *Complete All Applicable            |
| Rpr\] | Information           | Information*                        |
+-------+-----------------------+-------------------------------------+
| \[    | *Immediate Repair     |                                     |
| rprIm | Condition per         |                                     |
| med\] | ¶192.933(d)(1)?\      |                                     |
|       | (answer Yes or No)*   |                                     |
+-------+-----------------------+-------------------------------------+
| \[    | *One-Year Condition   |                                     |
| rpr1Y | per ¶192.933(d)(2)?\  |                                     |
| ear\] | (answer Yes or No)*   |                                     |
+-------+-----------------------+-------------------------------------+
| \[rpr | *Required Response    |                                     |
| Sch\] | Date\                 |                                     |
|       | per ASME B31.8S,      |                                     |
|       | Figure 4*             |                                     |
|       |                       |                                     |
|       | *(not applicable if   |                                     |
|       | either of above is    |                                     |
|       | answered Yes)*        |                                     |
+-------+-----------------------+-------------------------------------+
| \[r   | *Description of       |                                     |
| prDef | Defects Requiring     |                                     |
| ect\] | Repair*               |                                     |
+-------+-----------------------+-------------------------------------+
| \[r   | *Description of       |                                     |
| prRep | Required Remediation* |                                     |
| air\] |                       |                                     |
+-------+-----------------------+-------------------------------------+
| \[r   | *Reason for Delay\    |                                     |
| prRea | (include any factors  |                                     |
| son\] | outside operator\'s   |                                     |
|       | control)*             |                                     |
+-------+-----------------------+-------------------------------------+
| \[rpr | *Reason Why Pressure  |                                     |
| Press | Cannot be Reduced*    |                                     |
| ure\] |                       |                                     |
+-------+-----------------------+-------------------------------------+
| \[    | *Basis for Concluding |                                     |
| rprBa | that Delay will not   |                                     |
| sis\] | Jeopardize Public     |                                     |
|       | Safety*               |                                     |
+-------+-----------------------+-------------------------------------+
| \     | *Proposed Schedule    |                                     |
| [rprP | for Repair*           |                                     |
| lan\] |                       |                                     |
+-------+-----------------------+-------------------------------------+
| \[rpr | *Other Mitigative     |                                     |
| Mitig | Measures Planned*     |                                     |
| ate\] |                       |                                     |
+-------+-----------------------+-------------------------------------+

*NOTE: Leave this table blank except for Type 3 notifications.*

Table 7. Description of Affected Pipeline System/Segments (Type 2 and 3
Notifications Only)

  ------------------ ----------------------- ------------------------------------
  \[tblSys\]         Pipeline Information    *Complete All Applicable
                                             Information*

  \[sysSize\]        *Diameter (inches)*     

  \[sysMaterial\]    *Material*              

  \[sysWeld\]        *Weld Type*             

  \[sysCoatings\]    *Coatings*              

  \[sysMfgBy\]       *Manufacturer*          

  \[sysMfgTear\]     *Year Manufactured*     

  \[sysInstalled\]   *Year Installed*        

  \[sysDesignP\]     *Design Pressure*       

  \[sysMOP\]         *MAOP*                  

  \[sysWall\]        *Wall Thickness*        

  \[sysLastPig\]     *Date Last Pigged*      

  \[sysLastHydro\]   *Date of Last Hydro     
                     Test*                   

  \[sysLastDA\]      *Date of Last Direct    
                     Assessment*             

  \[sysPipeline\]    *Additional Details     
                     about Affected          
                     Pipeline*               

  \[sysLocation\]    *Affected Segment(s)    
                     Location\               
                     (milepost, county,      
                     state, etc.)*           

  \[sysHcaDesc\]     *Nature of HCA: Class 3 
                     or 4, Housing density,  
                     Identified Site*        
  ------------------ ----------------------- ------------------------------------

Table 8. Additional Information

  --------------- ----------------------------------------------------------------
  \[tblOther\]    *Other information relevant for regulatory review. If additional
                  supporting material has been supplied separately, provide a
                  brief description here.*

  \[otherText\]   
  --------------- ----------------------------------------------------------------

*\[End of Notification.\]*

## Additional Notes on Use of Template

### Suggested File Naming

*Suggested file naming and usage: This file is provided as a Microsoft
Word template (.dot file extension). When saving a
[completed]{.underline} notification, save the file as a Word document
(.doc extension). It is recommended that the file name include, at
minimum, an indication of: (1) operator name, (2) the word
\"notification\", and a revision and/or date.\
Example: **PittsburghGas_Notification_12-15-2004.doc***

### Specific Notes on Individual Fields

-   **General**

    a.  Leave any field [blank]{.underline} that does not apply. Do not
        enter text such as \"N/A\".

    b.  This template is designed to accommodate all three (3) distinct
        types of notifications. Depending on the type being submitted,
        entire sections of the template will not apply and should be
        left [blank]{.underline}.

    c.  Fields that require explanations or descriptions allow unlimited
        text. The tables will stretch as you type.

    d.  If you are providing additional supporting material, be certain
        to reference that material from the applicable fields, so that a
        reader will know that this material exists.

-   **Table 1**

    a.  **Date Notification Submitted:** enter in MM-DD-YYYY format.

    b.  **Affected States (2 fields):** List 2-letter state codes,
        separated by commas. If affected pipeline is interstate-only (or
        *vice versa*), leave the opposite field blank.

    c.  **Contact Information:** If the person submitting the
        notification is not the responsible manager, complete both sets
        of identification fields. Otherwise leave the second set blank.

-   **Table 2**

    a.  **Brief Summary Statement:** This should be a short paragraph,
        perhaps 1-3 sentences, providing a brief introduction to the
        purpose of the notification.

-   **Table 3**

    a.  **Notification Type:** Enter the letter \"X\" in the applicable
        row. Leave the other 2 rows blank.