Excavator or Utility Member filing report (Voluntary Only):

If you have provided your company name on the line above, do we have your permission to use your company's name on our published damage reports.

Yes No

Date of Damage to the underground facility (m/d/y):

City & County where damage occurred:

Address where damage occurred:

Right of Way where damage occurred: No Response Data Not Collected Dedicated Public Utility Easement Federal Land Pipeline Power Transmission Line Private (Bussiness) Private Easement Public (City Street) Public (County Rd) Private (Landowner) Public (Interstate Hwy) Public (Other) Public (State Hwy) Railroad Unknown/Other

Who damaged the facility?

Did the excavator notify the One-Call Center? Unknown Yes No

If yes, give the locate (ticket) number:      

Type of Excavation Equipment: Auger Backhoe/Trackhoe Boring Data Not Collected Drilling Directional Drill Explosives Grader/Scraper Hand Tools Vacuum Equipment Probing Device Trencher Unknown/Other

Type of work preformed: Agriculture Blading Bldg Construction Blgd Demolition Cable TV Curb/Sidewalk Data Not Collected Drainage Driveway Electric Engineering/Surveying Fencing Gas Irrigation Landscaping Lot Grading Petroleum Pipeline Pole Public Transit Authority Railroad Maint Road Work Sewer Storm Drain/Culvert Street Light Telecommunications Traffic Signal Transmission Pipeline Water Waterway Improvement Unknown/Other

Were the underground facilities located? Unknown Yes No

If yes, were they located properly? Unknown Yes No

What type of utility was affected? (Select all that apply):

Cable TV      Electric   Gas     Telephone    Wastewater    Water   Other  

If other, please list:

Estimated cost of damage/repair:  Unknown $0 - $5,000 $5,000 - $25,000 $25,000 - $50,000 Over $50,000

Did the damage cause an interruption of service? Unknown Yes No

If yes, approximately how many customers were affected? Unknown Zero One 2 - 10 10 - 50 50 or more

If the occurrence was a "near miss" please check here:

(A near miss is considered to be excavation that has been done on the easement or utility without authorization, in which there has not been any financial or utility damage.)

Additional Comments: