Utility Test

    Foreman name

    Laborer name

    Laborer name


    Date of accident

    Time of accident

    Time called UCI office for repair


    Utility repair confirmation no.

    Customer name

    Damaged utility company

    Utility technician name

    Utility technician phone #

    Utility technician arrival time

    Utility technician response

    Utility type of repairs

    Miss Dig ticket number

    Miss Dig work dates

    Miss Dig system check status? yesno

    UCI job number

    Street #, name city, state

    What was damaged?

    Damaged by handtool/machine?

    Description of damage:

    Utility staked? yesno

    Stakes off location? yesno

    If stakes off, how far?

    Types of marking(s) used:

    Pictures? yesno

    Foreman's signature:

    Supervisor's signature:

    Attach photos and/or drawings