Underground Facility Damage

Date reported

Cable/Internet

Electric

Natural Gas/Landfill Gas

Propane

Telecommunications

Water

Wastewater

Underground Facility Owner *

Your Name *

Your Email*

Date and Time Damage was Done*

:

Were there any fatalities as a result of this damage? *

Yes No

Name of Excavator causing the damage. *

Excavator Address

Address Line 1

City

State

ZIP Code

Excavator Email

Excavator Phone

Was Excavator working for the Facility Owner? *

Yes No

It not, then who?

How did the Facility Owner find out about the damage?

Excavator's Miss Utility Ticket Number?

Call Date for Mark-out

Was this an Emergency Ticket?

Yes No

Location of damaged facility (address, intersection, etc.) *

Address Line 1

Address Line 2

City

State

ZIP Code

Was the facility marked? *

Yes No

If so, by who?

How did the facility come to be damaged?*

Please select:*

Please comment*

Please select:*

Comment on root cause not known*

Was the damaged facility a main or a service? *

A Main A Service

Provide a brief description of the damaged facility *

Was the Excavator hand-digging?

Yes No

If not, what type of equipment was being used?

Was there an outage?

Yes No

If so, how long?

How many customers were affected

If customer was a business, provide name here

What is the cost to repair the damaged facility? *

Were there any injuries? *

Yes No

If so, describe

Was there any other damage to the surrounding area or property?

Yes No

If so, provide a summary and estimated cost to repair

Was there a disruption to traffic or any other activities?

Yes No

If so, describe

Other comments

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Underground Utility Facility Type

Facility Owners Only