Please complete this form as soon as your Adopt-A-Road group finishes a cleanup. Adopt-A-Road Contact InformationGroup NameContact Name* First Last Address Street Address Address Line 2 City ZIP / Postal Code Best Phone #Email* Cleanup DetailsDate of Cleanup* Location of Cleanup*# of Bags of Garbage Collected*# of Illegal Signs Collected*Approximate Weight of Garbage (20lbs/bag)# of Volunteers*# of Hours Worked*Do you need a DOT pickup?NoYesIf you are requesting a DOT pick-up, please make sure that all of the following apply. If not, please move the bags or items as requested below so that they can be collected.* Are the bags within the right-of-way (area between the street and the utility poles)? Are the bags at an intersection of two roads that you can give for directions? Are the bags placed together in an easily visible location? If you are requesting a DOT pickup, please provide the cross streets of the intersection where the bags/signs were left.*How would you improve the Adopt-A-Road program?Any other comments/suggestions?Photo UploadCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.