Free DT1205 ADOPT-A-HIGHWAY NOTICE OF ABANDONMENT - Wisconsin


File Size: 89.5 kB
Pages: 2
Date: April 28, 2009
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 621 Words, 4,196 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dot.wisconsin.gov/forms/docs/dt1205.pdf

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ADOPT-A-HIGHWAY NOTICE OF ABANDONMENT
DT1205 4/2009

Wisconsin Department of Transportation

Clear Form

Within thirty (30) days from your groups' decision to abandon activities, please complete this form and submit it to the department AAH coordinator listed for the county in which your segment was located. We prefer that you send your completed form via e-mail. You may also send it via the U.S Postal Service. See page 2 of this application for the appropriate e-mail or postal service address.
Date of Abandonment Group Name Location County Permit Number / Group Number

By electronic signature below, the Group representative hereby notifies the Department the Group has ceased activities and wishes to abandon this segment of highway enrolled in the Adopt-A-Highway Program. The Group also agrees to return all non-disposable materials provided by the Department to the County garage from where they were received. Upon completion of form DT1205, "Notice of Abandonment," the Group further acknowledges the Department will remove all signage for their Group and that the segment will immediately be available for adoption by others.

Signature of Authorized Group Representative - Must be 18 years or older Title

Date

We'd like to hear from you. In the space provided below please take the time to provide recommendations or suggestions for improving Wisconsin's Adopt-A-Highway program.

DO NOT WRITE BELOW THIS LINE The Department acknowledges the permitted group wishes to cease Adopt-A-Highway activities along the segment of highway identified above. The Department has hereby revoked the Adopt-A-Highway permit for the segment identified above. Roadside Adopt-A-Highway signs shall be removed and all non-disposable materials returned to the County garage where they were received.

Signature of Adopt-A-Highway Coordinator Authorized Group Representative - Must be 18 Title

Date

Permit Number Group Number

Thank you for participating in Wisconsin's Adopt-A-Highway Program.
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Adopt-A-Highway contact information

For additional Adopt-A-Highway program information, please contact the Adopt-A-Highway Coordinator listed for the same county in which your highway segment is located. Southwest Region Madison & La Crosse (Counties: Columbia, Crawford, Dane, Dodge, Grant, Green, Iowa, Jefferson, Juneau, Lafayette, La Crosse, Monroe, Richland, Rock, Sauk and Vernon) Coordinator: Donna Sanford 2101 Wright Street Madison, WI 53704 Phone: (608) 246-3871 Fax: (608) 246-5383 E-mail: [email protected]

Southeast Region - Waukesha (Counties: Kenosha, Milwaukee, Ozaukee, Racine, Walworth, Washington and Waukesha) Coordinator: Tina Hanson 141 NW Barstow St. Waukesha, WI 53187 Phone: (262) 548-5903 Fax: (262) 548-5662 E-mail: [email protected]

Northeast Region Green Bay (Counties: Brown, Calumet, Door, Fond du Lac, Kewaunee, Manitowoc, Marinette, Oconto, Outagamie, Sheboygan and Winnebago) Coordinator: Roy Tilleman 944 Vanderperren Way Green Bay, WI 54324 Phone: (920) 492-4125 Fax: (920) 492-5711 E-mail: [email protected]

North Central Region - Rhinelander (Counties: Adams, Florence, Forest, Green Lake, Iron, Langlade, Lincoln, Marathon, Marquette, Menominee, Oneida, Portage, Price, Shawano, Vilas, Waupaca, Waushara and Wood) Coordinator: Jane Nelson 510 North Hansen Lake Road Rhinelander, WI 54501 Phone: (715) 365-5758 Fax: (715) 365-5780 E-mail: [email protected]

Northwest Region - Eau Claire (Counties: Buffalo, Chippewa, Clark, Dunn, Eau Claire, Jackson, Pepin, Pierce, St. Croix and Trempealeau) Coordinator: Joan Frey-Pospishil 718 W. Clairemont Avenue Eau Claire, WI 54701 Phone: (715) 836-2831 Fax: (715) 836-2807 E-mail: [email protected]

Northwest Region - Superior (Counties: Ashland, Barron, Bayfield, Burnett, Douglas, Polk, Rusk, Sawyer, Taylor, Washburn) Coordinator: Joseph Whirry 1701 N. 4th St. Superior, WI 54880 Statewide Bureau - Madison James Merriman P.O. Box 7986 Phone: (608) 266-3943 4802 Sheboygan Avenue, Rm 501 Fax: (608) 267-7856 Madison, WI 53707-7986 E-mail: [email protected] Phone: (715) 392-7930 Fax: (715) 392-0879 E-mail: [email protected]