Download Report of Gas Facility Leak or Damage (1)

Maine Public Utilities Commission
Date of Report:
Underground Facility Incident Report
Incident #
(For Office Use)
Report Submitted By :
Excavator;
Facility Operator;
Other Party
Date of Incident
Time of Incident
AM / PM
Date Facility Operator Notified
Time Facility Operator Notified
AM / PM
Date Made Safe
Time Made Safe
AM / PM
Service Fully Restored
AM / PM
Dig Safe Notified
Yes
No
Dig SafeTicket #
GPS Coordinates
Incident Location
Long.
/
/
Street
Town
Type of Facility
Telephone
Electric
Damage To
Service Line
Distribution Line
Photos Held By
Excavator
Operator
Property Ownership
Public Right of Way
Gas
Tie Descriptions
CATV
Water
Transmission Line
Other Party
Sewer
Other (
Other
No Damage
Excavator Billed for Damage
Easement
Property Owner/Address
Lat.
)
Yes
No
Private
/
/
Owner
Street
Town
Describe Facility (Type, Size, Material, Pressure, etc
Describe the Activity causing damage or safety concern, citing any lack of precaution (if applicable)
Describe Damage (if applicable)
Number of Injuries
Number of Fatalities
Estimate of Property Damage $
Excavator Data
Facility Operator Data
Excavation Company
Facility Operator (Utility)
Address
Address
Street
Town
Telephone
Street
Zip
(
Town
)
Telephone
Zip
(
Name of Supervisor
Number of Outages
Equipment Operator
Evacuations
)
Equipment Description
Probable Cause :
[ ] Excavator failed to notify Dig Safe
[ ] Excavator failed to notify Nonmember operator
[ ] Excavator failed to premark
[ ] Excavator failed to maintain markings
[ ] Excavator failed to notify of damage to operator
[ ] Excavator failed to observe 18-in. safety zone
[ ] Excavator was reckless and/or negligent
[ ] Operator failed to mark in a timely manner
[ ] Operator failed to re-mark in a timely manner
[ ] Operator’s markings were Incorrect due to:
locator error
incorrect record
no record
[ ] Other
Comments
I declare that to the best of my knowledge and belief, the information I provided is true, correct, and complete.
Report Prepared By
For
Print Name
Signature
Company
Telephone
(
)
Submit to: Damage Prevention Administrator, Maine Public Utilities Commission, 18 State House Station,
Augusta, ME 04333 or fax to (207) 287-1039
Rev. 0507