MUFDPB Response Form

Mississippi Underground Facilities Damage Prevention Board Response Form

Mississippi Response Form to filed AVR

If you have multiple AVRs to respond to, please complete a separate response for each AVR.
AVR Number (Case #):
Maximum of 6 characters allowed. Currently Entered: 0 characters.
Example: 23-1
Date Response Filed Date Response Filed / MM / DD YYYY
Respondent information for alleged violation
Company Name
Company Title
Contact Name Contact Name First Last
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code United States
Phone Number Phone Number - ### - ### ####
Email Address
Were you previously aware of this alleged violation?

Were you previously aware of this alleged violation? Yes No Unknown
Excavation/Locate Request Information

if applicable
Was a locate request made?

Was a locate request made? Yes No Unknown
If so, Locate Request Number
Minimum of 14 characters required. Currently Entered: 0 characters.
Did excavation begin prior to the start date/time on the locate request?

Did excavation begin prior to the start date/time on the locate request? Yes No Unknown
Was the minimum horizontal clearance (tolerance zone) of 18" maintained between the marked facility and the mechanical equipment?

Was the minimum horizontal clearance (tolerance zone) of 18" maintained between the marked facility and the mechanical equipment? Yes No Unknown
If working in the tolerance zone, were the buried facilities exposed by hand or non invasive equipment used before excavating?

If working in the tolerance zone, were the buried facilities exposed by hand or non invasive equipment used before excavating? Yes No Unknown
Was the underground facility marked?

Was the underground facility marked? Yes No Unknown
Was the Excavation pre-marked with white paint noting the proposed area of excavation?

Was the Excavation pre-marked with white paint noting the proposed area of excavation? Yes No Unknown
Were the facilities marked accurately within the required tolerance zone?

Were the facilities marked accurately within the required tolerance zone? Yes No Unknown
Was reasonable care used to maintain the facility marks during the life of the project?

Was reasonable care used to maintain the facility marks during the life of the project? Yes No Unknown
Alleged Violation Response Information
If you dispute the allegations of the AVR, please use the text box below to explain your reasons.
Damage Information Response
Did damage occur as a result of the alleged violation?

Did damage occur as a result of the alleged violation? Yes No Unknown
Upload relevant photos or documents regarding the alleged violation.

Attach Files
I verify that the information submitted to the above referenced AVR number is correct to the best of my knowledge.

I verify that the information submitted to the above referenced AVR number is correct to the best of my knowledge. Yes

MUFDPB Response Form

MUFDPB Response Form

Mississippi Response Form to filed AVR

Respondent information for alleged violation

Excavation/Locate Request Information

Alleged Violation Response Information

Damage Information Response