Utility Damage Report

Crew Foreman or Self-Lead*

First Name

Last Name

Email

Dropdown email list

Person Completing Form

First Name

Last Name

Utility Type

Electricity Gas Fiber Optic TV Cable TV Water Sewer

Job Name

Job Number*

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Date and Time of Incident

:

Locate #

Station

Date Issued

Expiration Date

Renewal Date

Facility Owner

First Name

Last Name

Phone

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Locate Company Notified

Yes No

Date & Time

:

Locate Contact Person

First Name

Last Name

Phone

Public Service Commission Notified

Yes No

Date & Time

:

PSC Contact Person

First Name

Last Name

Phone

Log the Utility Damage Control #

Utility Company Notified

Yes No

Date & Time

:

Utility Contact Person

First Name

Last Name

Phone

Repair Supervisor On Site

First Name

Last Name

Phone

Who Accepted Responsibility

First Name

Last Name

Phone

Pothole to Locate

Provide a detailed explanation of the event(s) that lead to the damage.

Attach drawings, documents, or photos if needed.

No File Chosen

File uploads may not work on some mobile devices.

Superintendent

First Name

Last Name

Superintendent Signature

[clear]

Use your mouse or finger to draw your signature above

Foreman

First Name

Last Name

Foreman Signature

[clear]

Use your mouse or finger to draw your signature above