Call Before You Dig

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a report is required to be filed by the owner of underground facilities (16-345-3(a)(3) regulations of conn. state agencies). connecticut statutes allow the dpuc to levy a civil penalty up to $10,000 for failure to comply with anyprovision of the statute or regulations. this report may be used in actions imposing a civil penalty for violation of the statutes and regulations.

Therefore, FILL OUT THIS FORM ACCURATELY, AND FILE NOT LATER THAN THE 15th OF THE MONTH FOLLOWING THE INCIDENT. CBYD, Inc. acts as an information clearinghouse, and assumes no liability or prosecutorial position in compiling and transmitting these records.

This incident resulted in: (check one)	DAMAGE TO FACILITIES
	NO DAMAGE TO FACILITIES
This Report prepared on:	/ /

I. Teletype/Utility Code:
Utility Name:
Mailing Address:
City:
State:
Zip code:
Report prepared by:
Email:
II. Excavator involved in Incident:
Mailing Address:
City:
State:
Zip Code:
Contact Person:
Telephone:
Email:
III. Date & Time of Incident:	/ / time:
CBYD Ticket #:
Street address of Incident:
City:

Check Utility affected:		Check Facility:		Check Incident Location:
	Communications		Main		Public R.O.W.
	Water		Service		Private R.O.W.
	Sewer
	Electric
	Gas

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 excavation, or No emergency (explain in COMMENTS)	R Failure to exercise Reasonable Care (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, or incorrectly located	Z Located Incorrectly-Markout person error or omission

VIOLATIONS OF REGULATIONS-CHECK ALL 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 record; incorrect record
	Thickness of bituminous and concrete surface:	in.
	Cover over facility:	in.
2 Failure to wait 2 full working days -not an emergency	8 Failure to maintain marks		14 Failure to mark facilities-markout person error or omission
3 Failure to adequately and properly describe location	9 Failure to adequately support facilities		15 Failure to mark facilities-did not mark facilities-other (e.g.,no one dispatched)
4 Failure to renew notice (CBYD Ticket>30 days old)	10 Failure to report damages and contacts		16 Failure to mark accurately-no record, incorrect record
5 Failure to white line proposed work area	11 Unauthorized tampering with utility facilities		17 Failure to mark accurately-markout person error or omission
6 Improperly declared emergency	12 Failure to exercise reasonable care (describe under COMMENTS, below)

COMMENTS:

IV.	Did incident cause interruption of service? No Yes Time of outage
	Duration of outage: hours
	Number of customers affected by outage:
	Number evacuated: Number of personal injuries: Number of fatalities:
V.	Will excavator be billed for Incident? Yes No
VI.	Supervisor's Approval
	Job Title
	Approve Date
	Phone