NOTICE OF PROBABLE VIOLATION

Filing Fee - $200.00
Non-Refundable

Please provide all information requested below to assist in conducting a thorough investigation of this incident. This information will also help build a database to guide us in furthering damage prevention. Please use a separate report for each incident. Thank you for your time.

Thank you for submitting your Report of Probable Violation. The Maryland Underground Facilities Damage Prevention Authority will review your report and respond with our decision as to next steps. If you have any questions or concerns, please contact Jim Barron at 410-782-2102  or email us at info@mddpa.com.

Part A - Contact Information:

Maryland Underground Facilities Damage Prevention Authority
7223 Parkway Drive, Suite 210
Hanover, MD 21076

Part B - Who is submitting this information:


Who should be contacted if different than above?


Was this matter brought before the Local Damage Prevention Meeting?* Yes No

If so, when:*

I understand this is a non-refundable fee.

If you have any questions or concerns please contact us at the phone number or email address listed above.

Part C - Incident Info.: (incident date = date of discovery)

Incident Location:*

Public Property

Private Property

Utility Easement Latitude

City Right of Way

County Right of Way

State Right of Way Longitude

Name of party in violation:*

Contact information of party in violation:

*
*
*

Was there a statute violated?* Yes No Not Sure

If yes, please specify which statute was violated:*

Maryland Underground Facilities Damage Prevention Law: http://www.missutility.net/maryland/mdstatelaw.asp

Part D - Excavator Information:

Part E - Excavator Category:*

Contractor working for government
Contractor working for self
Contractor working for other
Contractor working for utility
Property owner/occupant
Municipality employee
Private individual
County employee
State employee
Utility employee
Railroad employee
Farmer
Developer
Unknown

Part F - Type of Excavation Activity:*

Agricultural
Bldg construction
Bldg demolition
Bldg reconstruction
Curb/sidewalk work
Drainage work
Driveway work
Fence work
Landscaping
Cable
Lot grading
Plumbing/septic work
Roadway maintenance
Site development
Traffic signal/system
Electricity
Telecommunications
Sewer
Gas
Water
Road construction
Setting poles
Sprinkler
Other
Parallel Excavation Yes No
Exposing (pot holing) facility Yes No

Part G - Type of Excavation

Equipment Type:*

Mechanical
Boring*
Hand
Explosive

Method of Excavation:*

Blasting
Boring*
Digging
Ditching
Dredging
Drilling
Driving
Grading
Hand Dig
Moving
Pavement Milling
Paving
Plowing
Razing
Removing
Rendering
Scraping
Tilling
Trenching
Tunneling
Wrecking
*If method is "boring", list boring technique Directional or Missle:

Part H - Description of damage

What type of facility was damaged?*

Water
Gas
Cable
Electric
Sewer
Telecommunications
Hazardous Liquid Pipeline
Other

Utility line function:

Service
Drop
Feeder
Trunk
Secondary
Primary
Transmission
Fiber
Main

Utility/Facility/Owner/Operator

Part I - Incident Impact:

Did the fire department respond? Yes No

Did the police department respond? Yes No

Was evacuation necessary? Yes No

Was traffic stopped or detoured? Yes No

Was there a service interruption? Yes No

Part J - Notification center information:

Did the person have a valid ticket? Yes No


Did the person check Underground Facilities Information Exchange System? Yes No

How: Phone Fax Back Website Email

Type of Ticket:

Regular 15 Working Day

Remark Notice

Designer

Emergency

Special Project

Meeting

Part K - Locating/Marking of Utility Line:

NOTE: Please attach, mail, or fax a copy of the "locator's manifest" and location sketch with this report if available.

Mail to: Maryland Underground Facilities Damage Prevention Authority, 7223 Parkway Drive, Suite 210 Hanover, MD 21076

Fax to: 410-712-0838

Who marked this line? Facility Owner/Operator Contract Locator

Was the line marked prior to the damage? Yes No

What types of marks were present? Paint Flags Stakes

Describe the condition of the marks in the proposed excavation area: Bright Visible Faded Destroyed No Marks

Were facilities visible (clear evidence) in the excavation area? Yes No


Were facilities marked in accordance with Maryland law and local practices? Yes No

Locator's Manifest:

Location Sketch:

Document 1:
Pay Now with Credit Card

Pay with Check
1. Your check should be made out to Maryland Underground Facilities Damage Prevention Authority

2. Mail your check to Maryland Underground Facilities Damage Prevention Authority, 7223 Parkway Drive, Suite 210 Hanover, MD 21076

3. Please note on your check "Probable Violation PV-2915-W"

Billing Information


My billing information is the same as my information in part B.

First Name:*
Last Name:*
Street:*
City:*
State:*
Zip Code:*
Phone:

Credit Card

Visa Mastercard Discover

Card Number:*
Expiration Date:*
 / 
CVV:*


*Required information.