Will you be working within 10 feet of any overhead power lines? YES NO

Type of Work ____________________________________________________________

Work being done for _____________________________________________________

SITE DESCRIPTION:

Address _______________________ Street____________________________________

Nearest Street Intersection ______________________

Distance/Direction from Intersecting Road:__________

Descriptive Detail __________________________________________________________________

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REMARKS __________________________________________________________________________

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Marked: WHITE PAINT STAKED FLAGGED

Depth: 30" ________________ Equipment: BACKHOE TRENCHER HAND DIG

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TWN ________________ RANGE _________________ SEC-QTR ________________

TWN ________________ RANGE _________________ SEC-QTR ________________

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Information Correct? YES NO