Utility Damage Report

• Company:

  Select Borton Greenhill Concrete Greenhill Materials Greenhill Sand Klaver Millennial Asphalt OCM Sherwood Construction Wildcat CO Wildcat KS Wildcat Concrete

  • Borton
  • Greenhill Concrete
  • Greenhill Materials
  • Greenhill Sand
  • Klaver
  • Millennial Asphalt
  • OCM
  • Sherwood Construction
  • Wildcat CO
  • Wildcat KS
  • Wildcat Concrete

• Project Name & Number:

• Conducted on

  Date

• Prepared by

Job Info

• Project Number:

• Road/Street Name:

• Town:

• Nearest address & stationing to hit

• Nearest Intersection to hit

• What side of road was utility hit on

  North

  South

  East

  West

Utility Location Information

• Was the Utility Notification Center (811) contacted prior to digging?

  Yes

  No

  Unknown

  N/A

• Ticket Number:

• Call In Date/Time

  Date

• Restake Date/Time

  Date

Damage Information

• Date and time of damage

  Date

• Utility Damaged

  Select Gas Phone Underground Electric Overhead Electric Cable DSL Water Sewer storm/culverts Irrigation Fiber Unknown

  • Gas
  • Phone
  • Underground Electric
  • Overhead Electric
  • Cable
  • DSL
  • Water
  • Sewer
  • storm/culverts
  • Irrigation
  • Fiber
  • Unknown

• Utility Owner

• Photo identifying location

  Media

• Photo of damage

  Media

• Photo of markings in area

  Media

• Additional photo if applicable

  Media

• Was damaged utility marked?

  Yes

  No

  N/A

• Was utility marked properly?

  Yes

  No

  N/A

• How was the utility marked

  Flag

  Whiskers

  Paint

• How many feet was the utility from the nearest mark?

• Was the utility potholed?

  Yes

  No

  N/A

• Describe damage and circumstances

• Name of Supervisor:

• Operator Involved (if applicable)

• Was the supervisor onsite when the incident occurred?

  Yes

  No

  Unknown

  N/A

• Equipment Involved

  Select Backhoe/Excavator Dozer Grader Loader/Skidsteer Scraper Mill/Pulverizer Trencher Hand Tools i.e. shovel, probe, etc. Truck (bed) Truck (equipment transport) Other

  • Backhoe/Excavator
  • Dozer
  • Grader
  • Loader/Skidsteer
  • Scraper
  • Mill/Pulverizer
  • Trencher
  • Hand Tools i.e. shovel, probe, etc.
  • Truck (bed)
  • Truck (equipment transport)
  • Other

• Equipment Number (If Applicable)

• Type of Work Being Performed

  Select Removal of culvert, curb, etc Removal of Trees, Stumps Placing Silt Fence Stripping Topsoil Sub-base/Excavation Placing Pipe Roadway Grading Milling/Pulverizing Excavating Other Installation of culvert, curb, inlet, etc

  • Removal of culvert, curb, etc
  • Removal of Trees, Stumps
  • Placing Silt Fence
  • Stripping Topsoil
  • Sub-base/Excavation
  • Placing Pipe
  • Roadway Grading
  • Milling/Pulverizing
  • Excavating
  • Other
  • Installation of culvert, curb, inlet, etc

• Root Cause of Hit

  Select 811 Not Called Digging before marked Markings disturbed Didn't hand dig in caution zone Not marked in a timely manner Inaccurate Markings No Markings in area Did not see overhead powerline No Spotter Other

  • 811 Not Called
  • Digging before marked
  • Markings disturbed
  • Didn't hand dig in caution zone
  • Not marked in a timely manner
  • Inaccurate Markings
  • No Markings in area
  • Did not see overhead powerline
  • No Spotter
  • Other

• Comments:

• Form completed by (sign)

  Sign

Utility Representative (If Applicable)

• Utility name and representative name

• Did utility agree as to fault?

  Yes

  No

  N/A

• Utility Rep Signature

  Sign

• Photo of utility rep's license plate

  Media