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 (Select ONE)

Type of Alleged Violation (Select ONE) 1. Excavating without a valid 811 locate ticket (all excavation types) (77-13-5) 2. Mechanically Excavated within 18 inches of the locate marks (77-13-5(1)(b)) 3. Locate Violation (all locate ticket types) (77-13-9) 4. Positive Response Violation (77-13-9(1)) 5. False Emergency Violation (77-13-11(3)) 6. Utility Owner/Operator is not a Member of Mississippi 811 (77-13-17(2)) 7. Failed to White Line as Required by Law (77-13-5(1)(c)) 8. Trenchless Excavation (Directional Boring) Violation (77-13-5(5)) 9. Submitted or renewed an 811 locate ticket for an area where excavation work was already completed (77-13-5(1)(c) and (2)) 10. Submitted an 811 locate ticket for an area that could not reasonably be completed within 14 days of submitting the ticket (77-13-5(1)(c)) 11. Violation after Damaging Utility 12. Other Violation not listed above (describe below)
Excavating without a valid 811 locate ticket - Detail

Excavating without a valid 811 locate ticket - Detail a. Dug without an 811 locate ticket (77-13-5(1)(c)) b. Dug after “expires” date/time on 811 locate ticket (77-13-5(2)) c. Dug prior to “locate by” date/time on 811 locate ticket (77-13-5(1)(c)) d. Dug outside the geographic scope included in 811 locate ticket (77-13-5(1)(c)) e. Other (describe) e. Other (describe)
Locate Violation - Detail

Locate Violation - Detail a. Located after “locate by” date/time on 811 locate ticket (77-13-9(1)) b. Did not locate buried utilities within scope of 811 locate ticket (77-13-9(1)) c. Locate marks more than 18 inches from buried utilities (77-13-9(1)(a), 77-13-3(b)) d. Located some, but not all buried utilities within scope of 811 locate ticket (77-13-9(1)) e. Other (describe) e. Other (describe)
Positive Response Violation - Detail

Positive Response Violation - Detail a. Did not use positive response (PRIS) (77-13-9(1)) b. Entered positive response (PRIS) information after “locate by” date/time on 811 locate ticket (77-13-9(1)) c. Reported incorrect information in positive response (PRIS)(77-13-9(1)) d. Other (describe) d. Other (describe)
False Emergency Violation - Detail

False Emergency Violation - Detail a. Excavation was not an emergency (77-13-11(3), 77-13-3(h)) b. Excavation was not an impending emergency (77-13-11(3), 77-13-5)(1(d), 77-13-3(w)) c. Other (describe) c. Other (describe)
Trenchless Excavation (Directional Boring) Violation - Detail

Trenchless Excavation (Directional Boring) Violation - Detail a. Failed to expose trenchless excavation path across/within the marked approximate location of utilities (77-13-5(5)) b. Failed to expose (pothole) utility on trenchless excavation parallel to the approximate location of the utilities (77-13-5)) c. Other (describe) c. Other (describe)
Violation after Damaging Utility - Detail

Violation after Damaging Utility - Detail a. Failed to notify Mississippi 811 and utility of damage (77-13-7(1)) b. Failed to notify 911, Mississippi 811 and utility of damage to gas utility (77-13-7(2))
Please provide additional information on any 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 damaged underground utility owner a member of Mississippi 811?
Date you became aware of Alleged Violation Date you became aware 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.
DATE/TIME STAMPED PHOTOS, VIDEOS, 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

DATE/TIME STAMPED PHOTOS, VIDEOS, 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.