Project Name*

Excavation / Observation ID*

Observer Name*

Observation Date*

Observation Time

Excavation Location / Address*

One-Call Ticket Number

Excavating Contractor*

Contractor Supervisor / Contact

Contractor Phone

Pipeline Operator / Facility Owner

Purpose of Excavation

Work Status at Time of Observation

Utility Locate Marks Visible & RespectedUtility Locate Marks Visible & Respected

Locate Mark Condition

Minimum Clearance to Facility (in)

Required Safe Clearance (in)

Per company policy or state regulation

Clearance Compliant

Potholing / Hand Dig Required Before MechanicalPotholing / Hand Dig Required Before Mechanical

Potholing / Hand Dig CompletedPotholing / Hand Dig Completed

Measured Depth to Facility (in)

As-Built Depth (in)

From records, if available

Damage to Facility OccurredDamage to Facility Occurred

Near-Miss IncidentNear-Miss Incident

Regulatory Report RequiredRegulatory Report Required

Overall Safety Compliance*

Stop Work Order IssuedStop Work Order Issued

Safety & Compliance Notes

Follow-Up Observation Visit RequiredFollow-Up Observation Visit Required

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