**US Department of Transportation**

**Pipeline and Hazardous Materials Safety Administration**

**Office of Pipeline Safety**

**Hazardous Liquid IMP Field Verification Inspection**

**49 CFR Parts 195.450 and 195.452**

> General Notes:

1.  This Field Verification Inspection is performed on field activities
    being performed by an Operator in support of their Integrity
    Management Program (IMP).

2.  This is a two part inspection form:

    i.  A review of applicable Operations and Maintenance (O&M) and IMP
        processes and procedures applicable to the field activity being
        inspected to ensure the operator is implementing their O&M and
        IMP Manuals in a consistent manner.

    ii. A Field Verification Inspection to determine that activities on
        the pipeline and facilities are being performed in accordance
        with written procedures or guidance.

3.  Not all parts of this form may be applicable to a specific Field
    Verification Inspection, and only those applicable portions of this
    form need to be completed. The applicable portions are identified in
    the Table below by a check mark. Only those sections of the form
    marked immediately below need to be documented as either
    "Satisfactory"; "Unsatisfactory"; or Not Checked ("N/C"). Those
    sections not marked below may be left blank.

Operator Inspected:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Op ID:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

  --------------- ---------- ----------------------------------------------
  Perform         Activity   Activity Description
  Activity        Number     
  *(denoted by               
  mark)*                     

                  1A         In-Line Inspection

                  1B         Hydrostatic Pressure Testing

                  1C         Other Assessment Technologies

                  2A         Remedial Actions

                  2B         Remediation -- Implementation

                  3A         Installed Leak Detection System Information

                  3B         Installed Emergency Flow Restrictive Device

                  4A         Field Inspection for Verification of HCA
                             Locations

                  4B         Field Inspection for Verification of Anomaly
                             Digs

                  4C         Field Inspection to Verify adequacy of the
                             Cathodic Protection System

                  4D         Field inspection for general system
                             characteristics
  --------------- ---------- ----------------------------------------------

**Hazardous Liquid IMP Field Verification Inspection Form**

**Name of Operator:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Headquarters Address:**

**Company Official:**

**Phone Number:**

**Fax Number:**

**Operator ID:**

  --------------------------- ------------------- ---------- -------------
  **Persons Interviewed**     **Title**           **Phone    **E-Mail**
                                                  No.**      

  **:**                       **Primary Contact**            

                                                             

                                                             

                                                             

                                                             
  --------------------------- ------------------- ---------- -------------

**OPS/State Representative(s):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Dates of Inspection: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

Inspector Signature:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Pipeline Segment Descriptions:** *\[note: Description of the Pipeline
Segment Inspected**.** (Include the pipe size, wall thickness, grade,
seam type, coating type, length, pressure, commodities, HCA locations,
and Pipeline Segment boundaries.)\]*

**Site Location of field activities:** *\[note: Describe the portion of
the pipeline segment reviewed during the field verification, i.e.
milepost/stations/valves/pipe-to-soil readings/river crossings/etc. In
addition, a brief description and case number of the follow up items in
any PHMSA compliance action or consent agreement that required field
verification. Note: Complete pages 8 & 9 as appropriate.\]*

### 

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**Summary:**

**Findings:**

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### [Key Documents Reviewed:]{.underline}

### 

+---------------------------------------+---------+-------+-----------+
| ### Document Title                    | ##      | #     | ### Date  |
|                                       | # Docum | ## Re |           |
|                                       | ent No. | v. No |           |
+---------------------------------------+---------+-------+-----------+
| ###                                   | ###     | ###   | ###       |
+---------------------------------------+---------+-------+-----------+
| ###                                   | ###     | ###   | ###       |
+---------------------------------------+---------+-------+-----------+
| ###                                   | ###     | ###   | ###       |
+---------------------------------------+---------+-------+-----------+
| ###                                   | ###     | ###   | ###       |
+---------------------------------------+---------+-------+-----------+
| ###                                   | ###     | ###   | ###       |
+---------------------------------------+---------+-------+-----------+
| ###                                   | ###     | ###   | ###       |
+---------------------------------------+---------+-------+-----------+
| ###                                   | ###     | ###   | ###       |
+---------------------------------------+---------+-------+-----------+

###  Part 1 - Performance of Integrity Assessments 

+-------------------------------+----+------+---+----------------------+
| ## 1A. In-Line Insp           | Sa | Un   | N | Notes:               |
| ection (Protocol 3.04 & 3.05) | ti | sati | / |                      |
|                               | sf | sfac | C | *\[Note: Add         |
|                               | ac | tory |   | location specific    |
|                               | to |      |   | information, as      |
|                               | ry |      |   | appropriate.\]*      |
+-------------------------------+----+------+---+----------------------+
| **Verify that Operator's O&M  |    |      |   |                      |
| and IMP procedural            |    |      |   |                      |
| requirements (e.g.            |    |      |   |                      |
| launching/receiving tools)    |    |      |   |                      |
| for performance of ILI were   |    |      |   |                      |
| followed.**                   |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify Operator's ILI       |    |      |   |                      |
| > procedural requirements     |    |      |   |                      |
| > were followed (e.g.         |    |      |   |                      |
| > operation of trap for       |    |      |   |                      |
| > launching and receiving of  |    |      |   |                      |
| > pig, operational control of |    |      |   |                      |
| > flow), as appropriate.      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify ILI tool systems and |    |      |   |                      |
| > calibration checks before   |    |      |   |                      |
| > run were performed to       |    |      |   |                      |
| > ensure tool was operating   |    |      |   |                      |
| > correctly prior to          |    |      |   |                      |
| > assessment being performed, |    |      |   |                      |
| > as appropriate.             |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify ILI complied with    |    |      |   |                      |
| > Operator's procedural       |    |      |   |                      |
| > requirements for            |    |      |   |                      |
| > performance of a successful |    |      |   |                      |
| > assessment (e.g. speed of   |    |      |   |                      |
| > travel within limits,       |    |      |   |                      |
| > adequate transducer         |    |      |   |                      |
| > coverage), as appropriate.  |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Document ILI Tool Vendor    |    |      |   |                      |
| > and Tool type (e.g. MFL,    |    |      |   |                      |
| > Deformation). Document      |    |      |   |                      |
| > other pertinent information |    |      |   |                      |
| > about Vendor and Tool, as   |    |      |   |                      |
| > appropriate                 |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify that Operator's      |    |      |   |                      |
| > personnel have access to    |    |      |   |                      |
| > applicable procedures       |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other:                      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ##  1B. Hydrostatic Pre       | Sa | Un   | N | Notes:               |
| ssure Testing (Protocol 3.06) | ti | sati | / |                      |
|                               | sf | sfac | C |                      |
|                               | ac | tory |   |                      |
|                               | to |      |   |                      |
|                               | ry |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| **Verify that hydrostatic     |    |      |   |                      |
| pressure tests complied with  |    |      |   |                      |
| Part 195 Subpart E            |    |      |   |                      |
| requirements.**               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review documentation of     |    |      |   |                      |
| > Hydrostatic Pressure Test   |    |      |   |                      |
| > parameters and results.     |    |      |   |                      |
| > Verify test was performed   |    |      |   |                      |
| > without leakage and in      |    |      |   |                      |
| > compliance with Part 195    |    |      |   |                      |
| > Subpart E requirements.     |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review test procedures and  |    |      |   |                      |
| > records and verify test     |    |      |   |                      |
| > acceptability and validity. |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review determination of the |    |      |   |                      |
| > cause of hydrostatic test   |    |      |   |                      |
| > failures, as appropriate.   |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Document Hydrostatic        |    |      |   |                      |
| > Pressure Test Vendor and    |    |      |   |                      |
| > equipment used, as          |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other:                      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 1C. Other Assessment       | Sa | Un   | N | Notes:               |
|  Technologies (Protocol 3.07) | ti | sati | / |                      |
|                               | sf | sfac | C |                      |
|                               | ac | tory |   |                      |
|                               | to |      |   |                      |
|                               | ry |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| **Verify that application of  |    |      |   |                      |
| "Other Assessment Technology" |    |      |   |                      |
| complied with Operator's      |    |      |   |                      |
| requirements, that            |    |      |   |                      |
| appropriate notifications had |    |      |   |                      |
| been submitted to OPS, and    |    |      |   |                      |
| that appropriate data was     |    |      |   |                      |
| collected.**                  |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review documentation of     |    |      |   |                      |
| > notification to OPS of      |    |      |   |                      |
| > Operator's application of   |    |      |   |                      |
| > "Other Assessment           |    |      |   |                      |
| > Technology", if available.  |    |      |   |                      |
| > Verify compliance with      |    |      |   |                      |
| > Operator's procedural       |    |      |   |                      |
| > requirements. If            |    |      |   |                      |
| > documentation of            |    |      |   |                      |
| > notification to OPS of      |    |      |   |                      |
| > Operator's application of   |    |      |   |                      |
| > "Other Assessment           |    |      |   |                      |
| > Technology" is available,   |    |      |   |                      |
| > verify performance of       |    |      |   |                      |
| > assessment within           |    |      |   |                      |
| > parameters originally       |    |      |   |                      |
| > submitted to OPS.           |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify that appropriate     |    |      |   |                      |
| > tests are being performed   |    |      |   |                      |
| > and appropriate data is     |    |      |   |                      |
| > being collected, as         |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other.                      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+

###  

### Part 2 - Remediation of Anomalies

+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 2A. Remedial Acti          | Sa | Un   | N | Notes:               |
| ons -- Process (Protocol 4.1) | ti | sati | / |                      |
|                               | sf | sfac | C |                      |
|                               | ac | tory |   |                      |
|                               | to |      |   |                      |
|                               | ry |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| **Verify that remedial        |    |      |   |                      |
| actions complied with the     |    |      |   |                      |
| Operator's procedural         |    |      |   |                      |
| requirements.**               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Witness anomaly remediation |    |      |   |                      |
| > and verify documentation of |    |      |   |                      |
| > remediation (e.g. Exposed   |    |      |   |                      |
| > Pipe Reports, Maintenance   |    |      |   |                      |
| > Report, any Data            |    |      |   |                      |
| > Acquisition Forms). Verify  |    |      |   |                      |
| > compliance with Operator's  |    |      |   |                      |
| > O&M Manual and Part 195     |    |      |   |                      |
| > requirements.               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify that Operator's      |    |      |   |                      |
| > procedures were followed in |    |      |   |                      |
| > locating and exposing the   |    |      |   |                      |
| > anomaly (e.g. any required  |    |      |   |                      |
| > pressure reductions, line   |    |      |   |                      |
| > location, identifying       |    |      |   |                      |
| > approximate location of     |    |      |   |                      |
| > anomaly for excavation,     |    |      |   |                      |
| > excavation, coating         |    |      |   |                      |
| > removal).                   |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify that procedures were |    |      |   |                      |
| > followed in measuring the   |    |      |   |                      |
| > anomaly, determining the    |    |      |   |                      |
| > severity of the anomaly,    |    |      |   |                      |
| > and determining remaining   |    |      |   |                      |
| > strength of the pipe.       |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify that Operator's      |    |      |   |                      |
| > personnel have access to    |    |      |   |                      |
| > applicable procedures.      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other:                      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 2B. Remediation - I        | Sa | Un   | N | Notes:               |
| mplementation (Protocol 4.02) | ti | sati | / |                      |
|                               | sf | sfac | C | Cathodic Protection  |
|                               | ac | tory |   | readings of pipe to  |
|                               | to |      |   | soil at dig site (if |
|                               | ry |      |   | available):          |
|                               |    |      |   |                      |
|                               |    |      |   | On Potential:        |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_   |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_mV |
|                               |    |      |   |                      |
|                               |    |      |   | Off Potential:       |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_   |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_mV |
|                               |    |      |   |                      |
|                               |    |      |   | *\[Note: Add         |
|                               |    |      |   | location specific    |
|                               |    |      |   | information, as      |
|                               |    |      |   | appropriate.\]*      |
+-------------------------------+----+------+---+----------------------+
| **Verify that the operator    |    |      |   |                      |
| has adequately implemented    |    |      |   |                      |
| its remediation process and   |    |      |   |                      |
| procedures to effectively     |    |      |   |                      |
| remediate conditions          |    |      |   |                      |
| identified through integrity  |    |      |   |                      |
| assessments or information    |    |      |   |                      |
| analysis.**                   |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > If documentation is         |    |      |   |                      |
| > available, verify that      |    |      |   |                      |
| > repairs were completed in   |    |      |   |                      |
| > accordance with the         |    |      |   |                      |
| > operator's prioritized      |    |      |   |                      |
| > schedule and within the     |    |      |   |                      |
| > time frames allowed in      |    |      |   |                      |
| > §195.452(h).                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review any documentation    |    |      |   |                      |
| > for this inspection site    |    |      |   |                      |
| > for an immediate repair     |    |      |   |                      |
| > condition                   |    |      |   |                      |
| > (§195.452(h)(4)(i) where    |    |      |   |                      |
| > operating pressure was      |    |      |   |                      |
| > reduced or the pipeline was |    |      |   |                      |
| > shutdown. Verify for an     |    |      |   |                      |
| > immediate repair condition  |    |      |   |                      |
| > that temporary operating    |    |      |   |                      |
| > pressure was determined in  |    |      |   |                      |
| > accordance with the formula |    |      |   |                      |
| > in Section 451.7 of         |    |      |   |                      |
| > ASME/ANSI B31.4 or, if not  |    |      |   |                      |
| > applicable, the operator    |    |      |   |                      |
| > should provide an           |    |      |   |                      |
| > engineering basis           |    |      |   |                      |
| > justifying the amount of    |    |      |   |                      |
| > pressure reduction.         |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify that repairs were    |    |      |   |                      |
| > performed in accordance     |    |      |   |                      |
| > with §195.422 and the       |    |      |   |                      |
| > Operator's O&M Manual, as   |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review CP readings at       |    |      |   |                      |
| > anomaly dig site, if        |    |      |   |                      |
| > possible. (See Part 4 of    |    |      |   |                      |
| > this form -- "Field         |    |      |   |                      |
| > Inspection to Verify        |    |      |   |                      |
| > adequacy of the Cathodic    |    |      |   |                      |
| > Protection System" , as     |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other:                      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+

###  Part 3 - Preventive and Mitigative Actions

+-------------------------------+----+------+---+----------------------+
| ## 3A. I                      | Sa | Un   | N | Notes:               |
| nstalled Leak Detection Syste | ti | sati | / |                      |
| m Information (Protocol 6.05) | sf | sfac | C | *\[Note: Add         |
|                               | ac | tory |   | location specific    |
|                               | to |      |   | information, as      |
|                               | ry |      |   | appropriate.\]*      |
+-------------------------------+----+------+---+----------------------+
| **Identify installed leak     |    |      |   |                      |
| detection systems on          |    |      |   |                      |
| pipelines and facilities that |    |      |   |                      |
| can affect an HCA.**          |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Document leak detection     |    |      |   |                      |
| > system components installed |    |      |   |                      |
| > on system to enhance        |    |      |   |                      |
| > capabilities, as            |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Document the frequency of   |    |      |   |                      |
| > monitoring of installed     |    |      |   |                      |
| > leak detection systems and  |    |      |   |                      |
| > verify connection of        |    |      |   |                      |
| > installed components to     |    |      |   |                      |
| > leak detection monitoring   |    |      |   |                      |
| > system, as appropriate,     |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other:                      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 3B. I                      | Sa | Un   | N | Notes:               |
| nstalled Emergency Flow Restr | ti | sati | / |                      |
| ictive Device (Protocol 6.06) | sf | sfac | C | *\[Note: Add         |
|                               | ac | tory |   | location specific    |
|                               | to |      |   | information, as      |
|                               | ry |      |   | appropriate.\]*      |
+-------------------------------+----+------+---+----------------------+
| **Verify additional           |    |      |   |                      |
| preventive and mitigative     |    |      |   |                      |
| actions implemented by        |    |      |   |                      |
| Operator.**                   |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Document Emergency Flow     |    |      |   |                      |
| > Restrictive Device (EFRD)   |    |      |   |                      |
| > component(s) installed on   |    |      |   |                      |
| > system.                     |    |      |   |                      |
| >                             |    |      |   |                      |
| > Note that EFRD per §195.450 |    |      |   |                      |
| > means a check valve or      |    |      |   |                      |
| > remote control valve as     |    |      |   |                      |
| > follows:                    |    |      |   |                      |
| >                             |    |      |   |                      |
| > \(1\) Check valve means a   |    |      |   |                      |
| > valve that permits fluid to |    |      |   |                      |
| > flow freely in one          |    |      |   |                      |
| > direction and contains a    |    |      |   |                      |
| > mechanism to automatically  |    |      |   |                      |
| > prevent flow in the other   |    |      |   |                      |
| > direction.                  |    |      |   |                      |
| >                             |    |      |   |                      |
| > \(2\) Remote control valve  |    |      |   |                      |
| > or RCV means any valve that |    |      |   |                      |
| > is operated from a location |    |      |   |                      |
| > remote from where the valve |    |      |   |                      |
| > is installed. The RCV is    |    |      |   |                      |
| > usually operated by the     |    |      |   |                      |
| > supervisory control and     |    |      |   |                      |
| > data acquisition (SCADA)    |    |      |   |                      |
| > system. The linkage between |    |      |   |                      |
| > the pipeline control center |    |      |   |                      |
| > and the RCV may be by fiber |    |      |   |                      |
| > optics, microwave,          |    |      |   |                      |
| > telephone lines, or         |    |      |   |                      |
| > satellite.                  |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Document the frequency of   |    |      |   |                      |
| > monitoring of installed     |    |      |   |                      |
| > EFRDs and verify connection |    |      |   |                      |
| > of installed components to  |    |      |   |                      |
| > monitoring/operating        |    |      |   |                      |
| > system, as appropriate.     |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify operation of remote  |    |      |   |                      |
| > control valve by having     |    |      |   |                      |
| > operator send remote        |    |      |   |                      |
| > command to partially open   |    |      |   |                      |
| > or close the valve, as      |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Comment on the perceived    |    |      |   |                      |
| > effectiveness of the EFRD   |    |      |   |                      |
| > in mitigating the           |    |      |   |                      |
| > consequences of a release   |    |      |   |                      |
| > on the HCA that it is       |    |      |   |                      |
| > designed to protect.        |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other:                      |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+

###  

***Part 4 - Field Investigations (Additional Activities as
appropriate)***

+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 4A. Field Inspection for   | Sa | Un   | N | Notes:               |
| Verification of HCA Locations | ti | sati | / |                      |
|                               | sf | sfac | C | *\[Note: Add         |
|                               | ac | tory |   | location specific    |
|                               | to |      |   | information, as      |
|                               | ry |      |   | appropriate.\]*      |
+-------------------------------+----+------+---+----------------------+
| **Review HCAs locations as    |    |      |   |                      |
| identified by the Operator.   |    |      |   |                      |
| Utilize NPMS, as              |    |      |   |                      |
| appropriate.**                |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify population derived   |    |      |   |                      |
| > HCAs in the field are as    |    |      |   |                      |
| > they appear on Operator's   |    |      |   |                      |
| > maps and NPMS, as           |    |      |   |                      |
| > appropriate. Document newly |    |      |   |                      |
| > constructed (within last    |    |      |   |                      |
| > 2-3 years) population       |    |      |   |                      |
| > and/or commercial areas     |    |      |   |                      |
| > that could be affected by a |    |      |   |                      |
| > pipeline release, as        |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
| >                             |    |      |   |                      |
| > Note that population        |    |      |   |                      |
| > derived HCAs are defined in |    |      |   |                      |
| > §195.450                    |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify drinking water and   |    |      |   |                      |
| > ecological HCAs in the      |    |      |   |                      |
| > field are as they appear on |    |      |   |                      |
| > Operator's maps and NPMS,   |    |      |   |                      |
| > as appropriate. Document    |    |      |   |                      |
| > newly established drinking  |    |      |   |                      |
| > water sources and/or        |    |      |   |                      |
| > ecological resources areas  |    |      |   |                      |
| > (within last 2-3 years)     |    |      |   |                      |
| > that could be affected by a |    |      |   |                      |
| > pipeline release, as        |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
| >                             |    |      |   |                      |
| > Note that unusually         |    |      |   |                      |
| > sensitive areas (USAs) are  |    |      |   |                      |
| > defined in §195.6           |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Verify commercially         |    |      |   |                      |
| > navigable waterway HCAs in  |    |      |   |                      |
| > the field are as they       |    |      |   |                      |
| > appear on Operator's maps   |    |      |   |                      |
| > and NPMS, as appropriate.   |    |      |   |                      |
| > Document any activity       |    |      |   |                      |
| > (commercial in nature) that |    |      |   |                      |
| > could affect the waterways  |    |      |   |                      |
| > status as a commercially    |    |      |   |                      |
| > navigable waterway, as      |    |      |   |                      |
| > appropriate.                |    |      |   |                      |
| >                             |    |      |   |                      |
| > Note that commercially      |    |      |   |                      |
| > navigable waterway HCAs are |    |      |   |                      |
| > defined in §195.450         |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 4B. Field Inspection for   | Sa | Un   | N | Notes:               |
| Verification of Anomaly Digs  | ti | sati | / |                      |
|                               | sf | sfac | C | *\[Note: Add         |
|                               | ac | tory |   | location specific    |
|                               | to |      |   | information, as      |
|                               | ry |      |   | appropriate.\]*      |
+-------------------------------+----+------+---+----------------------+
| **Verify repair areas, ILI    |    |      |   |                      |
| verification sites, etc.**    |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Document the anomaly dig    |    |      |   |                      |
| > sites reviewed as part of   |    |      |   |                      |
| > this field activity and     |    |      |   |                      |
| > actions taken by the        |    |      |   |                      |
| > operator.                   |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 4C. Field Inspe            | Sa | Un   | N | Notes:               |
| ction to Verify adequacy of t | ti | sati | / |                      |
| he Cathodic Protection System | sf | sfac | C | Cathodic Protection  |
|                               | ac | tory |   | readings of pipe to  |
|                               | to |      |   | soil at dig site (if |
|                               | ry |      |   | available):          |
|                               |    |      |   |                      |
|                               |    |      |   | On Potential:        |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_   |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_mV |
|                               |    |      |   |                      |
|                               |    |      |   | Off Potential:       |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_   |
|                               |    |      |   | \_\_\_\_\_\_\_\_\_mV |
|                               |    |      |   |                      |
|                               |    |      |   | *\[Note: Add         |
|                               |    |      |   | location specific    |
|                               |    |      |   | information, as      |
|                               |    |      |   | appropriate.\]*      |
+-------------------------------+----+------+---+----------------------+
| **In case of hydrostatic      |    |      |   |                      |
| pressure testing, Cathodic    |    |      |   |                      |
| Protection (CP) systems must  |    |      |   |                      |
| be evaluated for general      |    |      |   |                      |
| adequacy.**                   |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > The operator should review  |    |      |   |                      |
| > the CP system performance   |    |      |   |                      |
| > in conjunction with a       |    |      |   |                      |
| > hydrostatic pressure test   |    |      |   |                      |
| > to ensure the integrity     |    |      |   |                      |
| > assessment addressed        |    |      |   |                      |
| > applicable threats to the   |    |      |   |                      |
| > integrity of the pipeline.  |    |      |   |                      |
| > Has the operator reviewed   |    |      |   |                      |
| > the CP system performance   |    |      |   |                      |
| > in conjunction with the     |    |      |   |                      |
| > hydrostatic pressure test?  |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review records of CP        |    |      |   |                      |
| > readings from CIS and/or    |    |      |   |                      |
| > annual survey to ensure     |    |      |   |                      |
| > minimum code requirements   |    |      |   |                      |
| > are being met, if           |    |      |   |                      |
| > available.                  |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Review results of random    |    |      |   |                      |
| > field CP readings performed |    |      |   |                      |
| > during this activity to     |    |      |   |                      |
| > ensure minimum code         |    |      |   |                      |
| > requirements are being met, |    |      |   |                      |
| > if possible. Perform random |    |      |   |                      |
| > rectifier checks during     |    |      |   |                      |
| > this activity and ensure    |    |      |   |                      |
| > rectifiers are operating    |    |      |   |                      |
| > correctly, if possible.     |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| ## 4D. Field inspection for g | Sa | Un   | N | Notes:               |
| eneral system characteristics | ti | sati | / |                      |
|                               | sf | sfac | C |                      |
|                               | ac | tory |   |                      |
|                               | to |      |   |                      |
|                               | ry |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| **Through field inspection    |    |      |   |                      |
| determine overall condition   |    |      |   |                      |
| of pipeline and associated    |    |      |   |                      |
| facilities for a general      |    |      |   |                      |
| estimation of the             |    |      |   |                      |
| effectiveness of the          |    |      |   |                      |
| operator's IMP                |    |      |   |                      |
| implementation.**             |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Evaluate condition of the   |    |      |   |                      |
| > ROW of inspection site to   |    |      |   |                      |
| > ensure minimum code         |    |      |   |                      |
| > requirements are being met, |    |      |   |                      |
| > as appropriate.             |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Comment on Operator's       |    |      |   |                      |
| > apparent commitment to the  |    |      |   |                      |
| > integrity and safe          |    |      |   |                      |
| > operation of their system,  |    |      |   |                      |
| > as appropriate.             |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
| > Other                       |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+
|                               |    |      |   |                      |
+-------------------------------+----+------+---+----------------------+

**Anomaly Evaluation Report *(to be completed as appropriate)***

  -------------------------------------- --------------------------------
  **Pipeline System and Line Pipe        
  Information**                          

  Operator (OpID and System Name):       

  Unit ID (Pipeline Name)                

  Pipe Manufacturer and Year:            Seam Type and Orientation:

  Pipe Nominal OD (inch):                Seam Orientation:

  Pipe Nominal Wall thickness (inch):    Coating Type:

  Grade of Pipe:                         MOP:

  **ILI Reported Information**           

  ILI Technology (e.g., Vendor, Tools):  

  Anomaly Type (e.g., Mechanical, Metal  
  Loss):                                 

  Is anomaly in a segment that can       
  affect an HCA? (Yes / No)              

  Date of Tool Run (MM/DD/YY): Date of   
  Inspection Report (MM/DD/YY):          

  Date of "Discovery of Anomaly"         
  (MM/DD/YY):                            

  Type of "Condition" (e.g.; Immediate;  
  60-day; 180-day):                      

  Anomaly Feature (Int/Ext):             
  Orientation:                           

  Anomaly Details: Length (in): Width    
  (in): Depth (in):                      

  Anomaly Log Distance (ft): Distance    
  from Upstream weld (ft):               

  Length of joint of pipe in which       
  anomaly is identified (ft):            

  **Anomaly Dig Site Information         
  Summary**                              

  Date of Anomaly Dig (MM/DD/YY):        

  Location Information:                  

  Mile Post Number: Distance from A/G    
  Reference (ft):                        

  Distance from Upstream weld (ft):      

  GPS Readings (if available) Longitude: 
  Latitude:                              

  Anomaly Feature (Int/Ext):             
  Orientation:                           

  Length of joint of pipe in which       
  anomaly is found (ft):                 

  **For Mechanical Damage Anomaly**      

  Damage Type (e.g., original            
  construction, plain dent, gouge):      

  Length (in): Width (in): Depth (in):   

  Near a weld? (Yes / No):               

  Gouge or metal loss associated with    
  dent? (Yes / No):                      

  Did operator perform additional NDE to 
  evaluate presence of cracks in dent?   
  (Yes / No):                            

  Cracks associated with dent? (Yes /    
  No):                                   

  **For Corrosion Metal Loss Anomaly**   

  Anomaly Type (e.g., pitting, general): 

  Length (in): Width (in): Max. Depth    
  (in):                                  

  Remaining minimum wall thickness (in): 
  Maximum % Wall Loss measurement(%):    

  Safe pressure calculation (psi), as    
  appropriate:                           

  **For "Other Types" of Anomalies**     

  Describe anomaly (e.g., dent with      
  metal loss, crack, seam defect, SCC):  

  Length (in): Width (in): Max. Depth    
  (in):                                  

  Other Information, as appropriate:     

  Did operator perform additional NDE to 
  evaluate presence of cracks? (Yes /    
  No):                                   

  Cracks present? (Yes / No):            
  -------------------------------------- --------------------------------

**Anomaly Repair Report *(to be completed as appropriate)***

+-----------------------------------------------------------------------+
| **Repair Information**                                                |
+-----------------------------------------------------------------------+
| Was a repair of the anomaly made? (Yes / No):                         |
+-----------------------------------------------------------------------+
| Was defect ground out to eliminate need for repair? (Yes / No):       |
+-----------------------------------------------------------------------+
| If grinding used, complete the following for affected area:           |
|                                                                       |
| Length (in): Width (in): Depth (in):                                  |
+-----------------------------------------------------------------------+
| If NO repair of an anomaly for which RSTRENG is applicable, were the  |
| Operator's RSTRENG calculations reviewed? (Yes / No):                 |
+-----------------------------------------------------------------------+
| If Repair made, complete the following:                               |
+-----------------------------------------------------------------------+
| Repair Type (e.g., Type B-sleeve, composite wrap)                     |
+-----------------------------------------------------------------------+
| Length of Repair:                                                     |
+-----------------------------------------------------------------------+
| Comments on Repair material, as appropriate (e.g., grade of steel):   |
+-----------------------------------------------------------------------+
| Pipe re-coating material used following excavation:                   |
+-----------------------------------------------------------------------+
| **General Observations and Comments**                                 |
+-----------------------------------------------------------------------+
| Was a diagram (e.g., corrosion map) of the anomaly made? (Yes / No):  |
| (Include in report if available)                                      |
+-----------------------------------------------------------------------+
| Were pipe-to-soil cathodic protection readings taken? (Yes / No):     |
+-----------------------------------------------------------------------+
| If readings taken, Record: On Potential:                              |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_mV; Off Potential:                |
| \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_mV                                |
+-----------------------------------------------------------------------+
| Describe method used to Operator to locate anomaly (as appropriate):  |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| Comments regarding procedures followed during excavation, repair of   |
| anomaly, and backfill (as appropriate):                               |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| General Observations and Comments *(Note: attach photographs,         |
| sketches, etc., as appropriate)*:                                     |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+