Laserfiche WebLink
Filed for Record 05/04/2016 11 :09:49 AM -Kittitas County , WA Auditor -201605040003 Page 8 of 12 <br />IF UNDERGROUND DAMAGE <br />-------- ------------------------- -- <br />RIGHT-OF·WAYWHERE EVENT OCCURRED (CHOOSE ONE) <br />o CITY STREET 0 STATE HIGHWAY 0 COUNTY ROAD o INTERSTATE HIGHWAY 0 PUBLIC -OTHER o UNKNOWN/OTHER <br />o PRIVATE BUSINESS 0 PRIVATE LAND OWNER 0 PRIVATE EASEMENT o PIPELINE 0 RAILROAD o FEDERAL LAND <br />o POWERfTRANSMISSION LINE o DEDICATED PUBLIC UTILITY EASEMENT o DATA NOT COLLECTED <br />AFFECTED FACIUTY INFORMATION <br />WHAT TYPE OF FACILITY WAS AFFECTED? (CHOOSE ONE) <br />~ISTRIBUTION 0 SERVICE 0 TRANSMISSION o UNKNOWN/OTHER <br />EXCAVATION INFORMATION <br />TYPE OF EXCAVATOR (CHOOSE ONE) <br />o CONTRACTOR o OCCUPANT o COUNTY o DEVELOPER o FARMER o MUNICIPALITY <br />o RAILROAD o STATE o UTILITY o DATA NOT COLLECTED 0 UNKNOWN/OTHER <br />TYPE OF EXCAVATION EQUIPMENT (CHOOSE ONE) <br />o AUGER o BACKHOEfTRACKHOE o BORING o DRILLING o DIRECTIONAL DRILLING <br />o EXPLOSIVES o FARM EQUIPMENT o GARDEN/SCRAPER o HAND TOOLS o MIlLING EQUIPMENT <br />o PROBING DEVICE o TRENCHER o VACUUM EQUIPMENT o DATA NOT COLlECTED o UNKNOWN/OTHER <br />TYPE OF WORK PERFORMED (CHOOSE ONE) <br />o AGRICULTURE o CABLE TELEVISION o CURB/SIDEWALK o BLDG. CONSTRUCTION o BLDG . DEMOLITION <br />o DRAINAGE o DRIVEWAY o ELECTRIC o ENGINEERING/SURVEY o FENCING <br />o GRADING o IRRIGATION [] LANDSCAPING o LIQUID PIPELINE o MlLLING <br />o NATURAl GAs o POLE INSTALl.ATION o PUBLIC TRANSITAUTH . o RAILROAD MAINT. o ROADWORK <br />o SEWER (SANISTORM) o SITE DEVELOPMENT o STEAM o STORM DRAIN/CULVERT o STREET LIGHT <br />o TELECOMMUNICATION o TRAFFIC SIGNAL o TRAFFIC SIGN o WATER o WATERWAY IMPROVEMENT <br />o DATA NOT COLLECTED 0 UNKNOWN/OTHER <br />ONE CALL <br />DID EXCAVATOR CAlL FOR LOCATES? 0 YES 0 NO IF YES, WHEN <br />LOCATE NO .• WAS FACILITY PLATTED? 0 YES 0 NO YEAR PLATTED <br />WAS IT LOCATABLE? 0 YES 0 NO IF NO. WHY? <br />WERE MARKS CORRECT? 0 YES 0 NO IF NO. HOW FAR OFF? WAS FAClUlY MARKED? 0 YES 0 NO <br />WERE MARKS MAINTAINED? 0 YES 0 NO L OCATION OF MARKS I 1 YPE OF MARKS <br />WAS FACIUlY EXPOSED BY HAND? 0 YES 0 NO <br />DEPTH AT TIME OF DIG·IN <br />WAS LOCATOR ON SITE? 0 YES 0 NO <br />EXCAVATOR DOWNTIME VeRIFICATION <br />DID EXCAVATOR INCUR DOWNTIME? 0 YES 0 NO <br />o PAVEMENT 0 GRASS o OTHER <br />o DIRT o CURB <br />NAME OF LOCATOR REPRESENTATIVE <br />DID THE DAMAGE CAUSE AN INTERRUPTION OF SERVICE? 0 YES oNO o DATA NOT COLLECTED <br />COMPLETED BY (PLEASE PRINT) TITLE SIGNATURE <br />, o PAINT o OFFSET <br />o STAKE o OTHER <br />o UNKNOWNIOTHER <br />DATE <br />14 R.Al\f FL '/ 1))& <br />PAGE2OF2