Part B - Submitter Information

First Name:

Last Name:

Company:

Address:

City:

State:

Zip:

Email:

Work Phone:

Home Phone:

Mobile Phone:

Pager:

Fax:

Contact First Name:

Contact Last Name:

Contact Title:

Contact Company:

Contact Email:

Contact Work Phone:

Contact Mobile Phone:

Was This Matter Brought Before The LDPM:

If So, When:

Part C - Incident Information

Incident Date & Time:

Incident Address:

Incident City/County:

Incident Cause:

Incident Location:

Name Of Party In Violation:

Name:

Address:

Email:

Phone:

Was There A Statute Violated:

If yes, Please Specify Which Statute Was Violated:

Part D - Excavator Information

Name:

Company:

Address:

City:

Email:

Work Phone:

Home Phone:

Mobile Phone:

Pager:

Fax:

Part E - Excavator Category

Excavator Category:

Part F - Type of Excavation Activity

Excavation Activity:

Parallel Excavation:

Exposing Facility:

Part G - Type of Excavation

Equipment Type:

Method of Excavation:

Boring Technique:

Part H - Description of Damage

Type of Facility:

Utility Line Function:

Pressure:

Size:

Depth:


Utility/Facility/Owner/Operator
Contact:

Company:

Address:

City:

State:

Zip:

Email:

Work Phone:

Home Phone:

Mobile Phone:

Pager:

Fax:

Part I - Incident Impact

Did the fire department respond?

Did the police department respond?

Was evacuation necessary?

Was traffic stopped or detoured?

Was there a service interruption?

Excavation Down Time Cost:
$
Duration:

Number of Fatalities:

Number of Injuries:

Number of Customers Affected:

Damage Repair Cost:
$
Other Property Impacted:

Other Property Repair Cost:
$
Other Impact:

Part J - Notification Center Information

Did the person have a valid ticket?

Ticket Number:

Did the person check Underground Facilities Information Exchange System?

How:

Type of Ticket:

Part K - Locating/Marking of Utility Line

Locator's Name:

Company:

Address:

City, State, Zip:

Email:

Work Phone:

Mobile Phone:

Home Phone:

Pager Number:

Fax:

Was the line marked prior to the damage?

What types of marks were present?

Condition of the marks in the proposed excavation area:

Were facilities visible in the excavation area?

If "Yes", indicate record type:

Were facilities marked in accordance with Maryland law and local practices?

Additional Comments