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SECTION 1: COMPANY/LICENSEE INFORMATION
Licensee name: BA code:
Mailing address (include postal code):
Contact information (name, position, telephone number, e-mail address):
Proposed test date:
Signature of operating company responsible representative:
SECTION 2: PIPELINE SPECIFICATIONS
Pipeline Licence No.: Pipeline Line No.:
Total pipeline length to be pressure tested: m
Pipeline outside diameter: mm Pipeline MOP: kPa Licensed substance:
Pipe grade: MPa Pipe material:
Liquid test medium: Test medium composition: Water % Methanol % Other (please specify) %
Pipeline FROM location: Pipeline TO location:
Pipeline hoop stress (at max, test pressure; N/A for composite pipe): % SMYS Maximum test pressure: kPa
Test duration: hours
SECTION 3: PRESSURE TESTING GENERAL
1.Will the volume of any test section exceed 500 m3? Yes No
2.Will the hoop stress during the test exceed 100% SMYS of the pipe? Yes No
3.Does the pipeline cross or is it within 100 m of flowing water? Yes No
Locations of flowing water sites:
Names of flowing water sites that the pipelinecrosses or is within 100 m of:
Type of flowing water sites: Creek River Lake Other (e.g.,muskeg)
SECTION 4: SPILL CONTROL AND RECOVERY CONTINGENCY PLANS
Note: Where the responses to questions 1, 2, and 3 are NO, the licensee must develop contingency plans in accordance with Clause 8.7.2 of CSA Z662-11 to protect the environment in the event of leakage during testing.
If any response to question 1, 2, or 3 was YES, complete (4) through (10).
4.For a new welded steel pipeline, were all welds nondestructively inspected in accordance with Clause 7.10.4 or 16.9.3, as applicable, of CSA Z662-11, for the entire pipeline portion within 100 m of flowing water and all welds found unacceptable removed or repaired?
Yes No Not applicable
If NO, submit a request for deviation to , in accordance with Section 6.2, requirement 2.
5. Describe the contingency plan developed for immediate response in the event of a leak or spill of the liquid test medium.
6. Provide a detailed description of the spill containment methods that will be employed, including control points and equipment that will be available in the event of a release or spill occurring in preparation for, during, or following testing. (You may attach information.)
7. Provide an estimate of response and containment times.
8. Provide a description of spilled fluid recovery methods.
9. Explain where control equipment and personnel will be located.
10. Describe methods and location(s) for disposal of test medium.

Energy Resources Conservation Board Pipeline Technical Operations,Suite 1000, 250 – 5 Street SW, Calgary,AlbertaT2P 0R4