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, Filed 10r Record 05/04/2016 11 :09:49 AM -KittiREe~~A Auditor -201605040003 Page 7 of 12 <br />• PUGET SOUND ENERGY MAR 18 1.0\6 ORDERNO.~~ ~~ (~ ~ . <br />DAMAGE CLAIM N°'~_(rk -=----.V~ <br />REPORT OF DA~fiSOOEeL.ECTRIC FACILITIES <br />CONFIDENTIAL <br />PREPARED AT THE DIRECTION OF LEGAL COUNSEL <br />DATE OF INCIDENT ,) ~ (P -I Lr TIME ::6 (")(,)0 AM DATE OF REPORT '3 -7 -! 0 <br />REPORTED BY -f=P::....l,;;(v;J-1 *D~.------_______ INVESTIGATED BY 1-1 AlA I <br />LOCATION OF INCIDENT: STREET CITY G( Lfi;NJ(]Ug~OUNTY 1(,/ T 1\!TI:-tlS <br />TYPE OF <br />INCIDENT <br />DAMAGING <br />PARTY <br />INVESTIGATING <br />AGENCY <br />IF AUTOMOBILE <br />OR TRUCK <br />IFAPOLE IS <br />INVOLVED <br />WITNESSES <br />COMPANY <br />EMPLOYEES OR <br />SERVICE PROVIDER <br />AT SCENE OF <br />INCIDENT <br />2308 10112 <br />o POLE HIT o TREE IN LINE ~VERHEAD DAMAGE o PERSONAL INJURY <br />(DESCRIBE BELOW) <br />o UNDERGROUND DAMAGE <br />(J OTHER (DESCRiBE) <br />ACCIDENT INVESTIGATED? 0 YES 0 NO <br />o CITY OF <br />o STATE PATROL <br />o OTHER <br />o SHERIFF <br />o CASENO. <br />NAME AND BADGE NO. OF INVESTIGATING OFFICER(S) <br />MAKE MODEL YEAR <br />LICENSE NO . <br />NAME STREET <br />CITY ZIP <br />DRIVER'S LICENSE NO. D.O.B. STATE <br />NAME <br />ADDRESS <br />CITY STATE ZIP <br />INSURED? 0 YES AGENT <br />FIELD GRID <br />BUTT GAIN DATE ON POLE TRANSFORMER ON POLE 0 YES 0 NO <br />IF YES, TRANSFORMER 10 <br />STREET <br />CITY STATE ZIP PHONE NO. <br />NAME STREET <br />CITY STATE ZIP PHONE NO. <br />NAME STREET <br />CITY STATE ZIP PHONE NO. <br />NAME HEADQUARTERS <br />NAME HEADQUARTERS <br />NAME HEADQUARTERS <br />PAGE10F2