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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