Form-1 - Complaint Form 2000

ADVERTISEMENT

(For Official Use Only) Report No.______Case No._________Date___________
GEORGIA UTILITY FACILITY PROTECTION ACT
COMPLAINT FORM
(Please Complete All Applicable Information Truthfully and Legibly)
SECTION I: PERSONAL INFORMATION
COMPLAINANT________________________________________________________________
COMPANY____________________________________________________________________
ADDRESS____________________________________________________________________
CITY________________________________STATE________ZIP CODE___________________
FACILITY OWNER/OPERATOR___LOCATOR___EXCAVATOR___OTHER________________
HOME PHONE_(___)____________WORK _(___)______________CELL_(___)____________
FAX_(___)___________PAGER_(___)___________EMAIL_____________________________
_____________________________________________________________________________
ALLEGED VIOLATOR: __________________________________________________________
COMPANY____________________________________________________________________
ADDRESS____________________________________________________________________
CITY________________________________STATE__________ZIP CODE_________________
FACILITY OWNER/OPERATOR___LOCATOR___EXCAVATOR___OTHER________________
HOME PHONE_(___)____________WORK_(___)____________CELL_(___)_______________
FAX_(___)________PAGER_(___)________EMAIL___________________________________
COMPANY THAT LOCATED FACILITIES (IF APPLICABLE)____________________________
SECTION II: PROBABLE VIOLATION (PV) INFORMATION
PV DATE______TIME_______UPC LOCATE REQUEST NO.___________________________
PV ADDRESS_________________________________________________________________
CITY/TOWN__________________________COUNTY_________________________________
PUBLIC PROPERTY_____PRIVATE PROPERTY_______(Check One)
(Check One)
STATE RIGHT OF WAY____CITY R.O.W.____COUNTY R.O.W.___RAILROAD R.O.W.______
Page 3 of 5
GUFPA Form-1, Revised 08/20/00

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 3