Adopt-A-Highway Program

ACTIVITY REPORT

TODAY’S DATE:____________________________ MUNICIPALITY:_________________________

ADOPT-A-HIGHWAY GROUP:_______________________________________________________________

APPROXIMATE NUMBER OF GROUP PARTICIPANTS:_________________________________________

CONTACT PERSON:_______________________________________________________________________

PHONE NUMBER:_________________________________________________________________________

DATE GROUP CLEANED UP:_______________________________________________________________

HOURS INVOLVED: FROM____________________________ TO:____________________________

LOCATION:_____________________________________________________________________________

WHAT PORTION OF THE ASSIGNED AREA WAS PICKED UP BY THE GROUP:

________________________________________________________________________________________

APPROXIMATE NUMBER OF BAGS USED:

LITTER RECOVERED:

BOTTLES (#) CANS (#) OTHER

________________________ ________________________ ______________________________

GENERAL CONDITION OF RIGHT-OF-WAY BEFORE CLEANUP:______________________________

_______________________________________________________________________________________

LIST ANY REPORTS OF HAZARDOUS MATERIALS/LARGE ITEMS/DEAD ANIMALS:

_______________________________________________________________________________________

LIST ANY REQUESTS BY GROUP FOR TOWN OR MDOT TO PICK UP LITTER ON BRIDGES OR ON THE HIGHWAY: __________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

SUPERVISOR’S SIGNATURE: _________________________________