Utility Locator Assessment Form
Use this form to assess utility locating needs, site access, and field conditions before work begins.
Assessment Details
Project Name
*
Requester or Company Name
*
Job Site Address
*
City / State / ZIP
*
Requested Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Locator Request Type
*
New Locate
Re-mark
Update Existing Locate
Emergency Locate
Other
Site Conditions and Locate Scope
Site Type
*
Residential
Commercial
Industrial
Roadway
Vacant Lot
Other
Access Condition
*
Unrestricted
Gated
Limited Access
Requires Escort
Access Unknown
Surface Type
*
Soil
Grass
Pavement
Concrete
Mixed
Other
Overall Site Complexity
*
Low Complexity
1
2
3
4
5
6
7
8
9
High Complexity
10
1 is Low Complexity, 10 is High Complexity
Known Utility Types to Assess
*
Rows
Presence
Status
Notes
Electric
1
2
Gas
3
4
Water
5
6
Sewer
7
8
Telecom
9
10
Fiber
11
12
Storm Drain
13
14
Irrigation
15
16
Timing, Safety, and Follow-Up
Urgency Level
*
Routine
Priority
Urgent
Emergency
Site Notes and Special Instructions
Site Photos, Maps, or Supporting Documents
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Follow-Up Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Confirmation of Accuracy and Safety Conditions
*
I confirm that the information provided is accurate and that access/safety conditions have been described to the best of my knowledge
Submit Utility Locator Assessment Form
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