Utilities Form

Free Fillable DOT Compliance Checklist

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UP-0522 fieldscompliance

Project Information

Project Name*

Inspection ID*

Inspector Name*

Inspection Date*

Operator Name*

Operating Authority Number

Applicable Regulation(s)*

49 CFR Part 192 — Gas (Transmission & Distribution)49 CFR Part 195 — Hazardous Liquid Pipelines49 CFR Part 191 — Gas Incident ReportingState Pipeline Safety Regulations

Pipeline Type*

Class Location (Gas)

Regulation Reference & Inspection Items

Complete each inspection item with pass/fail status. Reference the applicable CFR section.

Key Compliance Areas

Summary assessment of primary compliance domains.

O&M Procedures — Current & Accessible

Emergency Response Plan — Current

Operator Qualification (OQ) — Current

CP Records — Up to Date

Leak Survey — Performed on Schedule

Damage Prevention Program — Active

Pass/Fail Status & Corrective Actions

Overall Compliance Status*

Number of Violations Found

Corrective Actions Required

Corrective Action Due Date

Regulatory Notification RequiredRegulatory Notification Required

Inspector Notes

Photos

Location

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