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Form No. 4479 <br />Reported By: Fa, rp'."t <br />❑ Planned Outage <br />Location: I ower f.tin r_ i . en �o <br />❑ Unplanned Outage <br />'6 t fir" <br />X Equipment/Property Damage <br />Feeder: S L <br />❑ Customer Problem <br />❑ Power Quality/Service Issue <br />Fill out all blocks and be specific as possible. <br />Include drawings, photos, additional narrative as <br />0 Other: <br />needed. <br />INCIDENT REPORT AND POWER INTERRUPTION FORM <br />. .- <br />First Responder <br />Na <br />Name: Date: WO# <br />s � � <br />Date of Incident: <br />Time Power Off: <br />Time Power On: <br />Time Reported: <br /># of Customers affected <br />Customer Hrs Off: <br />12-7$-Lol <br />L/,00 <br />Nature of,jDama%]e and Immediate Action Taken: (attach /Spare sheet if needed) ,} <br />Ly --0tru.( zo Wks j-'; t 0 -IC R(n Mcje/1 F✓uM C_0 � ' 1 t, Gltl.nl`r�, <br />Pole,P _'4 Ly <br />PO 6 <br />Follow -Up Work Required: X Yes ❑ No (If yes, explain below) <br />ThwG l; y s/�tc®' FQP or* of pole tIN!-u'-1-uta I'6k <br />InterruptionCause of <br />Law EnforcemenUFire Investigation Report: <br />❑ Yes ❑ No If Yes, Agency: Officer: Contact #: <br />❑ Trees ❑ Fire <br />❑ Wildlife ❑ Flooding <br />PUD Vehicles Used: 13 6 LENTnI,f .4 <br />Q� Vehicle ❑ Natural <br />4 t <br />— sez, 64ctctlu.il W. 0.7 T— <br />/Lk Dig up/Construction Equipment ❑ Other: <br />Outside Crew Used: ❑ Yes IX No <br />PUD Employees Called Out: r� <br />.$'f 0rp.. If -5:30 Hrs: I',ZZ Meals: <br />Company Name: <br />i44—e-r4e—r 54'— Hrs: -7 Meals: <br />l }use kfi-r S YLI/`I Hrs: '_ Meals: <br />No. of Employees: Hrs Worked: <br />KJC' t CL7 1411 Hrs::— Meals: <br />Hrs: Meals: <br />Reimbursable: K Yes ❑ No'r`tilr <br />t r 14:00-S,00 <br />V"i?'W I Z I b 4f -00 <br />Liable Party at Fault <br />Con act Informat on of Rlsponsible Party: <br />K��;}�� c.�n roa cr,—, <br />Witness(s): C1 Yes ❑ No (If yes, insert information below) <br />y <br />First Responder Signature: <br />Date: <br />M nag Signature: <br />Date: <br />12-)5_Z,l7 <br />IZ i <br />WAD - Kittitas PUD Shared DrivelForm Template Incident -Power Interruption Form 2015.docx <br />