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