UNDERGROUND FACILITIES/UTILITIES
VIOLATION REPORT FORM

The purpose of this form is to allow law enforcement to review the information provided for possible violations of the Louisiana Underground Utility/Facility Damage Prevention Law.

Please fill out the form completely or your form may not be processed. Hazardous material complaints should be reported directly to the Louisiana State Police.
la_one_call.gif (5155 bytes)
[FrontPage Save Results Component]
Who is Submitting This Form
Date (mm/dd/yyyy)
LA One Call Member
 Member Code
Name of Person Completing This Form
 Daytime Phone
Excavator Information
Excavator Name Phone
Excavator's Company Name
Address
 Fax
City
 e-Mail
State
 Zip
Type of Excavator
Description (If you chose "Other" above)
Description of Root Cause
Description (If you chose "Other" above)
Event Date and Location
Location of excavation/damage 
City
 Parish
 Date  (mm/dd/yyyy)
Affected Utility/Facility
Description (If you chose "Other" above)
How did you find out about the damage?
Damages
Duration of Outage
 Number of Injuries
Approximate Number Customers Affected
 Number of Fatalities