Underground Facilities Alleged Violation Reporting Form

Please Note: Only one alleged violation/violator per form.

Your Name
Your Company
Your Email
Your Street Address
Address Line 2
City
Postal / Zip Code
State
Today's Date Today's Date / MM / DD YYYY
Phone Phone - ### - ### ####
Company/Person that Committed the Alleged Violation
Phone Number for Alleged Violator (if known) Phone Number for Alleged Violator (if known) - ### - ### ####
Email Address for Alleged Violator (if known)
Mailing Address for Alleged Violator (if known)
Street Address
Address Line 2
City
Postal / Zip Code
State
Type of Alleged Violation

Type of Alleged Violation 1. Excavating without a one call ticket 2. Excavating early 3. Mechanical excavating within the marks 4. Failure to locate 5. Did not locate within the required time 6. Other (describe below)
Please provide a description of the alleged violation
Did a damage occur as a result of this violation?

Did a damage occur as a result of this violation? Yes No
Utility Type

Utility Type Gas Electric CATV Phone Water Sewer Other
Gas Line

Gas Line Service Line Main Line
Electric Line

Electric Line Service Line Main Line
CATV Line

CATV Line Service Line Main Line
Phone Line

Phone Line Service Line Main Line
Sewer Line

Sewer Line Service Line Main Line
Water Line

Water Line Service Line Main Line
Other
Locate Ticket Number (if known)
Must be 14 characters. Currently Entered: 0 characters.
Enter Ticket Number Only
Is the underground utility owner a member of Mississippi 811?
Date of Alleged Violation Date of Alleged Violation / MM / DD YYYY
Time of Alleged Violation Time of Alleged Violation : HH MM AM/PM
Location of Alleged Violation
Street Address
Address Line 2
City
Postal / Zip Code
County
State
Please provide driving directions to location
Upload a Image/File

Attach Files

Attachments must not have symbols in the file name. Example:( $, &, *, % ) etc.
PHOTOS, SKETCHES, WITNESS STATEMENTS AND ANY OTHER DOCUMENTATION TO SUPPORT YOUR COMPLAINT MUST BE ATTACHED WHEN SUBMITTING THIS FORM IN ORDER TO BE CONSIDERED BY THE ENFORCEMENT BOARD.

Underground Facilities Alleged Violation Reporting Form

Underground Facilities Alleged Violation Reporting Form

PHOTOS, SKETCHES, WITNESS STATEMENTS AND ANY OTHER DOCUMENTATION TO SUPPORT YOUR COMPLAINT MUST BE ATTACHED WHEN SUBMITTING THIS FORM IN ORDER TO BE CONSIDERED BY THE ENFORCEMENT BOARD.