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AECOM <br /> Structures: Possible horizontally installed <br /> facilities,vaults, basements,tunnels,sub- ❑Yes❑No ❑Yes ❑ No ❑Above <br /> grade structures,foundations, overhead <br /> obstructions, etc. <br /> UST Systems (Tanks/piping/electric) ❑Yes❑No ❑ Yes❑ No <br /> Sewer: =Sanitary,storm, combined, <br /> septic, drainage(parking, buildings,fields), ❑Yes❑No ❑ Yes❑ No <br /> irrigation <br /> Water:[M Process, Plant, potable,well, <br /> cooling, return/makeup,fire, sprinkler, ❑Yes❑No ❑Yes ❑ No ❑Above <br /> landscape irrigation, reclaim ' • - other <br /> Other: Abandoned lines, invisible dog <br /> fences,shopping cart perimeter monitoring, ❑Yes❑No ❑Yes ❑ No ❑Above <br /> traffic lights <br /> Manager: <br /> Print Sign Date <br /> Underground Utilities&Subsurface Installations Clearance Checklist(S3AM-331-FM1) <br /> Revision 1 September 30,2020 <br /> PRINTED COPIES ARE UNCONTROLLED. CONTROLLED COPY IS AVAILABLE ON COMPANY INTRANET. Page 4 of 4 <br />