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