Utility Test

Foreman name

Laborer name

Laborer name

Office

Date of accident

Time of accident
:

Time called UCI office for repair
:

Contacted

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
to

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