FRA F 6180.8a Special Repair Remedial Action Report

OMB No. 2130-0504
U.S. Department of Transportation
Federal Railroad Administration

Special Repair Remedial Action Report
Part 2

Instructions: Once remedial action has been completed, please complete this form describing in detail the repairs made. Send this report immediately to the Chief Mechanical Officer
(Locomotive or Car), or the Chief Engineer (Track), of your company for his/her approval. Mail this report to the Regional Administrator whose address appears at the lower right corner of
the companion, Special Notice For Repair Report, Part 1.

1. Name of Inspector:

2. ID Number:

6. Operating Railroad:

3. SNFR Report No.:

7. RR Initials:

11. Date:

10. County:

8. City:

9. State:

14. Track No., Location, Description, etc.:

16. State:

20a. Line Item No.:

5. Inspection Rpt. No.:

In compliance with the Special Notice For Repair Report issued by the inspector whose
name appears above, the following remedial action was taken to comply wit h applicable
Federal Regulations:

12. Time:

13. Locomotive or Freight/Passenger Car Initials & No.:

15. Location Repaired: City:

4. Region:

17. Date Repaired:

18. Time Repaired:

19. Remedial Action Codes:

21a. CFR, Rule, & Subrule:

22a. Defects:

23a. Repair Details:
21b. CFR, Rule, & Subrule:

20b. Line Item No.:
22b. Defects:

23b. Repair Details:
21c. CFR, Rule, & Subrule:

20c. Line Item No.:
22c. Defects:

23c. Repair Details:
21d. CFR, Rule, & Subrule:

20d. Line Item No.:
22d. Defects:

23d. Repair Details:
20e. Line Item No.:

21e. CFR, Rule, & Subrule:

22e. Defects:

23e. Repair Details:
24. Certification: I certify that the above report is correct:
Name: (Print and Signature)

Title:

25. Officer in charge of Repairs: (Chief Mechanical Officer or Chief Engineer)
Name: (Print and Signature)

Title:

26. Notary Public: (Required on locomotive repairs)
Subscribed and sworn to before me on ___________________________, in the State of ___________________________, County of __________________________,
by _________________________, known personally to me to be ________________________, for the company at ___________________________.
Notary Public
Section 1001, Title 18, United States Code, provides: "Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick,
scheme, or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes or uses any false writi ng or document knowing the same to contain any false, fictitious, or
fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both."

Form FRA F6180.8A

9/04

Form FRA F 6180.8A (07/10)

Expires XX/XX/XXXX

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Special Repair Remedial Action Report

OMB No. 2130-0504

Public reporting
burden for this information collection is estimated to average 15 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing
and reviewing the collection of information. According to the Paperwork Reduction Act of 1995, a federal agency may not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently
valid OMB control number. The valid OMB control number for this information collection is 2130-XXXX. All responses to
this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this
collection, including suggestions for reducing this burden to: Information Collection Officer, Federal Railroad
Administration, 1200 New Jersey Ave., N.W., Washington D.C. 20590.

Form FRA F 6180.8A (07/10)

Expires XX/XX/XXXX

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