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MUST be filled out PRIOR to the Start of Field Activities NO subsurface work in road Right of Ways or Off-Site (property boundary) without Written Authorization Site Address: If Present -- Site Safety Documents (on-site during activities) "Yes or No" Fill Out, as applicable Utility Staking Request Form (properly completed for current scope of work)? Yes No Ticket # and Expir. Date: # Site Health and Safety Plan? Yes No Hospital Location Map Available Yes No Identify on a Site Map the Location of ALL Lines & Meters (or actual utility) and Utility Identification "color" Above Ground (AG) / Buried (B) Indicate Nearest Building Quadrant (NE, SE, SW, or NW) Natural Gas (Yellow) / Staked? AG / B Yes No NW NE SE SW Electrical (Red) / Staked? AG / B Yes No NW NE SE SW Telephone/Fiber Optic (Orange) / Staked? AG / B Yes No NW NE SE SW Cable TV (Orange) / Staked? AG / B Yes No NW NE SE SW Water (Blue) / Staked? AG / B Yes No NW NE SE SW Sewer (Green) / Staked? AG / B Yes No NW NE SE SW Significant Site Features UST system (UST cavity, dispenser islands, piping runs, vent pipes etc.)? Above Ground Storage Tanks — ASTs (dispenser islands, piping runs)? Electrical Transformers? Area Lighting (Pole mounted lighting, etc.)? Signage with electrical power (Business/Company signs, etc.)? Underground lawn/landscaping sprinkler system? Storm drain catch basins / man-ways and potential connecting conduits/lines? Other Pavement distress (Cracked pavement, "buckled" asphalt, etc.)? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Site Feature Located in Closest Property Quadrant (NE, SE, SW, or NW). Also Identify on Site Map. "Other" Concerns Located in Closest Property Quadrant (NE, SE, SW, or NW). Identify on Site Map. *Buried utilities can be found at any depth, but are most often found within the first 5 feet below the ground surface. Proceed slowly and with extra caution when working within 5 feet of the ground surface. NOTES: SIGNATURE DATE