NPV FORM

A

Contact Information

Subscriber ID

First Name*

Last Name*

Company

Email*

Work phone*

Mobile phone

Address*

City*

State*

Zip

Who should be contacted if different from above?

Contact First Name

Contact Last Name

Contact Title

Contact Company

Contact Email

Contact Work Phone

Contact Mobile Phone

Was this matter brought before the Local Damage Prevention Meeting?

Yes/No*

If so, when?

I understand this is a non-refundable fee. If you have any questions or concerns please contact us at the phone number or email address listed above.

B

Incident information

Date of incident*

Incident time

City/County*

Incident location (public/private)

Address*

Contact information of party in violation

Company name*

Company address*

Company phone*

Company email*

Contact first name*

Contact last name*

Contact email

Contact phone*

Contact address*

Contact city*

Contact state*

Contact ZIP

Was there a statute violated?

Yes / No / Not sure*

When was the statute violated?*

If yes, please specify which statute was violated:*

C

Excavator Information

First name*

Last name*

Company*

Email

Work phone*

Mobile phone*

Address*

City*

State*

ZIP

D

Type of work*

E

Type of Excavation

F

Description of Damage

G

Incident Impact

Did the fire department respond?

Yes / No

Did the police department respond?

Yes / No

Was evacuation necessary?

Yes / No

Was there a service interruption?

Yes / No

# of Fatalities

# of Injuries

# of Customers Impacted

H

Notification Center Information

Did the person have a valid ticket?

Yes / No

Ticket #

Did the person check Underground Facilities Information Exchange Sytem?

Yes / No

How

I

Locating/Marking of Utility Line

Note:

Please attach, mail, or fax a copy of the “locator’s manifest” and location sketch with this report if available. Mail to: Maryland Underground Facilities Damage Prevention Authority, 7223 Parkway Drive, Suite 210 Hanover, MD 21076 Fax to: 410-712-0838

Who marked this line?

Facility Owner / Operator or Contract Locator

First Name

Last Name

Company

Email

Work phone

Mobile phone

Address

City

State

Zip

Was the line marked?

Yes / No

What types of marks were present?

Paint

Flags

Stakes

Describe the condition of the marks in the proposed excavation area.

Bright

Visible

Faded

Destroyed

Were facilities visible (clear evidence) in the excavation area?

Yes / No

If yes, indicate record type

Were facilities marked in accordance with Maryland law and local practices?

Yes / No

Additional Comments

Additional Documents

Total size of attached documents is limited to 25MB. Any supporting documentation can also be emailed direct to jim.barron@mddpa.org.

Document 1

Certification

By typing my full name in the space provided

I hereby certify that I am competent to testify as a witness and I am over the age of 18 years. Further, I solemnly affirm under the penalties of perjury that the contents of the foregoing facts are true to the best of my knowledge, information and belief. *

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J

Review

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Notice of Probable Violation

Contact Information

Who should be contacted if different from above?

Was this matter brought before the Local Damage Prevention Meeting?

Incident information

Contact information of party in violation

Was there a statute violated?

Excavator Information

Type of work*

Parallel Excavation?

Exposing (pot holing) facility?

Type of Excavation

Equipment Type*

Method of Excavation*

If boring, list boring technique

Description of Damage

Was there a damage?*

If yes, what type of facility was damaged?

What type of utility line function?

Incident Impact

Did the fire department respond?

Did the police department respond?

Was evacuation necessary?

Was there a service interruption?

Notification Center Information

Did the person have a valid ticket?

Did the person check Underground Facilities Information Exchange Sytem?

Locating/Marking of Utility Line

Note:

Who marked this line?

Was the line marked?

What types of marks were present?

Describe the condition of the marks in the proposed excavation area.

Were facilities visible (clear evidence) in the excavation area?

Were facilities marked in accordance with Maryland law and local practices?

Additional Comments

Additional Documents

Certification

Review