Free DT1207 - Wisconsin


File Size: 83.8 kB
Pages: 3
Date: March 31, 2009
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 698 Words, 4,595 Characters
Page Size: Letter (8 1/2" x 11")
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http://www.dot.wisconsin.gov/forms/docs/dt1207.pdf

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ADOPT-A-HIGHWAY FREEWAY / INTERSTATE / INTERCHANGE WORK PLAN
Wisconsin Department of Transportation DT1207 4/2009

Group Name WisDOT Contact

Group E-Mail Address WisDOT Contact Telephone

Group Number

This work plan is to assure a safe clean-up of the freeway or interstate highway segment or interchange that you have adopted. All rules in the Terms and Conditions in the Adopt-A-Highway Application/Permit are to be followed except as modified below. General Conditions 1. 2. 3. All participants must be at least 16 years of age. No other persons shall be at the clean-up site. No more than 20 participants shall be allowed to do clean-up at the same time. Participants shall work facing traffic. Participants may walk with the direction of traffic when they are along the fence line (or at least 15 feet from the highway pavement if there is no fence line.) Participants shall not cross any lanes of traffic, drive on service vehicle crossovers, or work on the median between opposing lanes of traffic. The group leader shall report any accidents or other safety problems that occur while the group is cleaning its segment. The WisDOT contact name and telephone number is listed above. Violation of AAH safety rules may be grounds for removal from the program.

4.

5.

Site-specific conditions and layout plan as written and prepared by WisDOT representative (see attachments.) 6. Installation of person-working cautionary signs (show how signs and the locations will be installed and removed without interrupting traffic.)

7.

Parking (parking on or along freeway/interstate is not allowable.)

8.

Participants walking plan (walk facing traffic, walk with traffic only when away from the roadside, walk back to vehicles or be picked up at a site not by the freeway/interstate).

9.

Other special conditions (bridges, tunnels, overpasses, other structures, steep inclines, wet areas) to deal with.

10.

Map of area showing parking, walking plan, and other special conditions.

The group leader shall talk with a DOT representative so that the work plan is understood. Prior to clean-up, the leader shall brief members about the plan. By electronic signature below, the Group agrees to the work plan above. Please send your signed work plan via email to the contact on page 3.

(Signature of Authorized Group Representative Must be 18 years or older)

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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: donna.sanford@dot.wi.gov

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: tina.hanson@dot.wi.gov

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: roy.tilleman@dot.wi.gov

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: jane.nelson@dot.wi.gov

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: joan.freypospishil@dot.wi.gov

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: james.merriman@dot.wi.gov Phone: (715) 392-7930 Fax: (715) 392-0879 E-mail: joseph.whirry@dot.wi.gov