Tri-County EMC Potential Hazard Report
Date:
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Month
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Day
Year
Date
Pole Number:
Service Address:
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Guy Wire
Anchor
Clearance (Primary)
Clearance (Secondary)
Span Length
Conductor
Pole
Insulator
Cross Arm
Apparatus
Photo of Hazard
Photo of Hazard
Other
Reported By:
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Date:
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Month
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Day
Year
Date
Action Taken:
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Date:
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Month
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Day
Year
Date
Repaired By:
Date Submitted:
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Month
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Day
Year
Date
Date Completed:
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Month
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Day
Year
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Submitted by:
First Name
Last Name
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