Pember Companies Utility Hit Sheet

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

Utility Hit Sheet Form Fields

• Who Did You Notify?

• Description of Utility Hit

• Digger / Locate #

• Was the utility properly located prior to Hit?

  Yes

  No

  N/A

• Add Photos of Damage Including location of utility Marks

  Media

• Name of Locator / Company:

• Type of Utility Hit?

• Utility Owner:

• Date and Time utility owner was notified:

  Date

• We're repairs conducted while you were present?

  Yes

  No

  N/A

• Time Repairs were Started:

  Date

• Time Repairs were completed:

  Date

• Job cost code:

• Estimated Delay/ Down time:

• Who was the Operator?

• Equipment is Use / Equipment #

• Names of Laborers on site:

• Names & Phone numbers for witnesses on site:

• Foreman's Signature & Date:

  Sign

• For Office Only: Date Received: _______________ By:___________________________________ Who will follow up? ______________________________________________________ Will this Become an Insurance Claim? ___________ What Corrective Measures are Warranted to Prevent in Future? _______________________________________________________________________