NPV Form

Notice of Probable Violation

A
Contact Information
Who should be contacted if different from above?
Was this matter brought before the Local Damage Prevention Meeting?
  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
Contact information of party in violation
Was there a statute violated?
C
Excavator Information
D
Type of work*
Parallel Excavation?
Exposing (pot holing) facility?
E
Type of Excavation
Equipment Type*
Method of Excavation*
If boring, list boring technique
F
Description of Damage
What type of facility was damaged?*
What type of utility line function?
G
Incident Impact
Did the fire department respond?
Did the police department respond?
Was evacuation necessary?
Was there a service interruption?
H
Notification Center Information
Did the person have a valid ticket?
Did the person check Underground Facilities Information Exchange Sytem?
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?
Was the line marked prior to the damage?
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

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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