Alleged Violation Report Form

Please Note: Only one violation per form.

Name Name First Last
Text
Company
Your Address Your Address
Street Address City State / Province / Region Postal / Zip Code
Today's Date Today's Date / MM / DD YYYY
Your Phone Number Your Phone Number - ### - ### ####
Your Email
Company/Person that Committed Alleged Violator (If Known)
Phone Number for Alleged Violator (If Known) Phone Number for Alleged Violator (If Known) - ### - ### ####
Email Address for Alleged Violator (If Known)
Mailing Address for Alleged Violator (If Known) Mailing Address for Alleged Violator (If Known)
Street Address City State / Province / Region Postal / Zip Code
Type of Alleged Violation
Did a damage occur as a result of this violation?
Locate Ticket Number (if known)
Maximum of 10 characters allowed. Currently Entered: 0 characters.
Is the underground facility owner a member of West Virginia 811?
Date/Time of Alleged Violation if Known Date/Time of Alleged Violation if Known / MM / DD YYYY
: HH MM AM/PM
County
Location of Alleged Violation Location of Alleged Violation
Street Address City
Please provide driving directions to the location
Please upload any photos and/or other documentary evidence

Attach Files