Subsurface Utility Clearance Variance

Subsurface Utility Clearance Variance

All required fields must be filled in order to submit the form.
Project Name*
Site Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Office Location*
OM Email
example@example.com
OHSM Email
example@example.com
CHSD Email
example@example.com
Submitter Name*
Submitter should be project, senior, principal, or VP-level personnel
Submitter Email
example@example.com
Project Manager*
PM Email
example@example.com
Project Principal*
Principal Email
example@example.com
Fieldwork Start Date

MonthDayYear
Date
One-Call Ticket Number*
Description of Intended Subsurface Work*
Has GPR investigation been performed of the intended subsurface work areas?*

YesNo
Justification and Description of Variance to Roux Subsurface Clearance Procedures*
Describe which Roux subsurface clearance procedures will require a variance and the nature of the variance.
List the steps to be taken to mitigate potential risk of a utility strike to an acceptable level*
Does the proposed variance require additional technical review?*

YesNo
Are there any other hazards, mitigating actions, or site-specific concerns that need to be considered?*

YesNo
Please indicate other hazards, mitigating actions, or site-specific concerns
Does the project team have backup documentation (e.g., site plan, sampling locations, utility plans)?*

YesNo
Please upload relevant backup documentation

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