Utility Contractors/excavators Incident Report Form

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Please send original report to CBYD and a copy to UCAC. Fill out even if there is no damage.
CBYD
UCAC
2040 Whitney Avenue
145 New London Turnpike, Suite 1133
Glastonbury, CT 06033
Hamden, CT 06517
Utility Contractors/Excavators Incident Report Form
Please fill out this form accurately, and file not later than the 15
day of the month following the incident.
th
(Duplicate forms as needed)
This incident resulted in: (check one) ____ DAMAGE TO FACILITES ____ NO DAMAGE
Company Name: _____________________________________ CBYD Contractor #__________ Date ___________
Mailing Address:_______________________________________________________ _ Email: ____________________
Report Prepared By: _________________________________________________ Tele. _________________________
Utility Involved in Incident:_________________________________________________________________________
Date & Time of Incident: _________________________________ CBYD Ticket # __ __ __ __ __ __ __ __ __ __ __
Town: ___________________________ Street Address of Incident: ________________________________________
Circle Utility Affected:
Circle Facility:
Circle Incident Location:
A. Communications B. Electric
C. Gas
F. Main
H. Public R.O.W.
D. Sewer
E. Water
G. Service
I. Private R.O.W.
If DAMAGE resulted, enter ONLY ONE primary cause letter code from the Table below: [
]
M. No Notice (no CBYD ticket)
P. Failure of excavator to maintain marks
N. Not located - Markout person error or omission
Q. Failure to hand dig (required for gas facilities only.)
O. Not located; less than 2 full working days – Emergency
R. Failure to exercise reasonable care (explain in COMMENTS)
excavation, or No Emergency (explain in COMMENTS)
S. Not located – Incorrect or Incomplete notice
X. Failure to stay within the proposed work area
V. Not located – Incorrect record
W. Located Incorrectly – Incorrect record of facility
U. No record of facility – not located, or incorrectly located
Z. Located Incorrectly – Markout person error or omission
VIOLATIONS of regulations - enter ALL numbers that apply from the TABLE below [________]
EXCAVATOR AT FAULT
FACILITY OWNER/OPERATOR AT FAULT
1. No Notice (no CBYD ticket)
7. Failure to hand dig (gas only)
13. Failure to mark facilities – No
Thickness of bituminous and
record; incorrect record
Concrete surface ___in.
Cover over facility ___ in.
2. Failure to wait 2 full working days
8. Failure to maintain marks
14. Failure to mark facilities - markout
not an emergency
person error or omission
3. Failure to adequately and properly
9. Failure to adequately support
15. Failure to mark facility – did not
describe location
facilities
mark facilities – other (e.g. no one
dispatched
4. Failure to renew notice (CBYD
10. Failure to report damages and
16. Failure to mark accurately – no record,
Ticket over 30 days old)
contacts
incorrect record
5. Failure to white line proposed
11. Unauthorized tampering with utility
17. Failure to mark accurately – markout
work area
facility
person error or omission
6. Improperly declared emergency
12. Failure to exercise reasonable care
(describe under COMMENTS)
Will utility company be billed for incident? Yes ___ No ___
Will excavator be billed for incident? Yes __ No ___
COMMENTS:________________________________________________________________________________________
_____________________________________________________________________________________________________
Signed: _____________________________________________________________
Rev. 9/2014

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