D-4181-Uc, 2014, Utility Relocation Clearance Report Instructions printable pdf download

D-4181-Uc, 2014, Utility Relocation Clearance Report Instructions

Appendix A

Publication 16 (DM-5)

Figure A-1100

Page 1 of 3

(09/14)

D-4181-UC (9-14)

UTILITY RELOCATION

CLEARANCE REPORT

INSTRUCTIONS



State Route – Identify the state route for the proposed facilities.



Station to Station or Segment & Offset to Segment & Offset – Identify the location of the

proposed facilities.



RT/LT – Identify if the proposed facilities are right or left of the highway centerline.



Brief Description of the Adjustment – Identify the type of work required for the

relocation/adjustment (i.e., install new pole, relocate gas line, etc.).



Type of Relocation - Each Location – Identify the type of relocation for each location. See the

definitions for the different types of relocations on the form.



Describe Conditional Restrictions or Time Requirements for Coordinated Work – Identify any

conditional restrictions or time requirements for the utility work, including sequencing of utility

work. See the definitions for the different types of relocations on the form.



Calendar Days Required or Date of Completion – Identify how many calendar days are required

to complete the work for each location. For PRIOR work, give the anticipated or actual

completion date.

o If applicable, the utilities should also include time to order material, the sequencing of

operations between utilities and scheduling crews and outages.



Sign and Date the form.



If needed, attach additional sheets to list additional information.

D-4181-Uc, 2014, Utility Relocation Clearance Report Instructions