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A=COM Part 1 and Part 2 shall be completed prior to any intrusive subsurface work. DO NOT DISTURB GROUND if a "No"or "N/A"answer to any of the Part 1 questions has not been initialed as authorized by the AECOM Manager. Any variance from these procedures requires approval of the Vice President of the applicable business group. Yes No I N/A Comments: Documentation supplied by one-call or private utility and installation locators, including email or written field confirmation/maps of mark-out requests and status shall accompany this form. If this form is supporting multiple ground disturbance activities,a copy of this completed form should be provided to each activity, Part 2 Public Utility Locate(OneCall) Prior Locate Ticket# Date Called: Called By: Valid Until: Ticket Number: Area Requested To Be Cleared: Private Utility Locate Prior Locate Ticket# Company Performing Locate: Date Completed: Area(s)Requested To Be Cleared (including distance around marked locations): Method(s)Used (e.g., GPR, EM): Confirm Area(s)Cleared: OneCall Utilities Field Observation Utility Notified by Comments Marked(mains&services) Electric_ ❑ OneCall ❑ Other ❑Yes ❑ No ❑Above Gas/Petroleum Pipeline (Yellow) ❑ OneCall ❑ Other ❑Yes ❑ No Sewer/Drainage ❑ OneCall ❑ Other ❑Yes ❑ No Water= ❑ OneCall ❑ Other ❑Yes ❑ No Communications(Orange) ❑ OneCall ❑ Other ❑Yes ❑ No ❑Above Other ❑ OneCall ❑ Other ❑Yes ❑ No ❑Above Were all circuits on during subsurface checks if the checks were for identifying energized lines ❑Yes ❑ No ❑ N/A (e.g., circuits on timers or light sensing switches)? Utilities Not Identified By OneCall Field Observation Includes both Public and Private along with Regional and Site Utilities Utility Colors may vary) Owner/Contact/Phone# Notified Marked Communications: (Orange)TV, computer, phone, cell towers, site communication, ❑Yes❑No ❑ Yes ❑ No ❑Above cameras, security, etc. Electricity:=Mains/Supplies/Interior /Exterior(signs, fuel pumps, low voltage security perimeters, gates, property light ❑Yes❑No El Yes El No El Above posts, equipment, substations,etc. Gas: (Yellow)Mains/Supplies/Equipment/ Pipelines (Natural, Process, Oil, Crude, ❑Yes❑No ❑Yes ❑ No ❑Above Refined Gas, Diesel,Jet), etc. Steam: (Yellow) ❑Yes[:]No ❑Yes ❑ No ❑Above Underground Utilities&Subsurface Installations Clearance Checklist(S3AM-331-FM1) Revision 1 September 30,2020 PRINTED COPIES ARE UNCONTROLLED. CONTROLLED COPY IS AVAILABLE ON COMPANY INTRANET. Page 3 of 4