Department of Labor & Industry - Bureau of Labor Law Compliance - Underground Utility Line Protection Act

The Underground Utility Line Protection Law is no longer in effect as of April 28, 2018. However, any incidents that took place prior to that date can still be reported to the Bureau of Labor Law Compliance for investigation.

If an incident took place after April 28, 2018, you should visit the Pennsylvania Utility Commission for instructions on how to report those matters. You can find information on their website http://www.puc.state.pa.us/consumer_info/transportation/pa_one_call.aspx

Within 10 business days of the incident, complete this form and press the submit button at the end. Digital pictures cannot be attached to this online submission. Please e-mail them to RA-LI-SLMR-LLC@pa.gov with a text message to the BLLC asking that the pictures be attached to the Incident Report form along with the Confirmation Number.

If you are facility owner or excavator, is your organization a member of the Pennsylvania One Call system, Inc?

*

YES NO

Reported By
First Name:	*		City:	*
Initial:			State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Last Name:	*		Zip Code:	*
Company Name:	*		Telephone:	*
Address - Line 1:	*		Fax:
Address - Line 2:			E-mail:

Excavator Performing Work
Company Name:	*
Contact Person:
First Name:	*		City:	*
Initial:			State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Last Name:	*		Zip Code:	*
Address - Line 1:	*		Telephone:
Address - Line 2:			Fax:
			E-mail:

Nature and scope of excavation:	*
Type of equipment being used:
Date excavation started(mm/dd/yyyy):	*
Time of excavation started(hh:mm am/pm):	*
Was the area marked in white?	*	YES NO
Was PA ONE CALL contacted? If so, fax or mail copy.*	*	YES NO
POCS Serial #:	*
Was it called in as an emergency?	*	YES NO
Nature of emergency:	*
Did the facility owner respond to KARL?	*	YES NO
What was the response?	*
Date of response(mm/dd/yyyy):	*
Time of response(hh:mm am/pm):	*

Incident Information
Date of Incident(mm/dd/yyyy):	*		Address - Line 1:	*
Time of Incident(hh:mm am/pm):	*		Address - Line 2:
Facility Name:	*		City:	*
First Name of Owner:	*		State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Initial:			Zip:	*
Last Name of Owner:	*		Municipality:	*
			County:	*	---Select--- None Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York Out of State

Damage to facility?:	*	YES NO
Type of facility:	*	Electric Gas/Oil Communications Water Sewer Other
Size of facility (diameter):	*
Facility Use:	*	Transmission Distribution Service Other
(Explain Other)	*	Please limit to 250 characters or less.
Right of Way:	*	Public Private
Interruption of service:	*	YES NO
Duration of Interruption:	*

Start Date(mm/dd/yyyy):	*		End Date(mm/dd/yyyy):	*
Start Time(hh:mm am/pm):	*		End time(hh:mm am/pm):	*
Number of customers affected:	*		Number of customers evacuated:	*

Were lines located?	*	YES NO UNKNOWN
Date lines were marked(mm/dd/yyyy):	*
Time lines were marked(hh:mm am/pm):	*
Was size indicated?	*	YES NO
Colored Indicator:	*	Paint Mark Arrow Stake Dot Flag Other
Personal injury?	*	YES NO
Number injured?	*
Death?	*	YES NO
Number fatalities:	*

In the event of damage, did the excavator notify the facility owner?	*	YES NO
Evacuate/alert resident(s)?	*	YES NO
1. If you are a facility owner reporting a hit, was the hit made by your employees?		YES NO N/A
2. If you are a facility owner reporting a hit, was the hit made by a contractor that you hired?	*	YES NO N/A
3. If you are a facility owner reporting a hit, did you hit another facility owner's line?	*	YES NO N/A
4. If you are a contractor/excavator reporting a hit that you made, were you hired by the facility owner of the line that you hit?	*	YES NO N/A
5. If this was a gas line hit, was it a gas transmission or gas distribution line?	*	YES NO N/A
Explanation of Incident: (Attach extra paper if necessary)
Provide a detailed sketch of the incident area: (Attach extra paper if necessary) To accurately describe the incident, please include the following (1) direction of north, (2) the underground utilities, roads, fixed landmarks, etc, (3) location of incident using distance landmarks, (4) the location of paint or flags placed by the facility owner and (5) the distance between the incident and the paint or flags.
Whom do you represent?	*	Facility Designer Excavator Citizen
I hereby verify that the statements contained in this Incident Report are true and correct to the best of my knowledge, information and belief. I understand that false statements made are subject to the penalties of 18 Pa. C.S.A. 4904, relating to unsworn falsification to authorities. Agree Disagree If Disgree is selected the Incident will be submitted but can not be Investigated