Form TR-0103 "Adopt-A-highway Permit Application" - California

Form TR-0103 or the "Adopt-a-highway Permit Application" is a form issued by the California Department of Transportation.

Download a PDF version of the Form TR-0103 down below or find it on the California Department of Transportation Forms website.

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Download Form TR-0103 "Adopt-A-highway Permit Application" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PERMIT NO.
ADOPT-A-HIGHWAY PERMIT APPLICATION
TR-0103 (REV 09/2009)
DIST/CO/RTE/PM
FOR CALTRANS USE
(Date Received)
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (Section 552, et. seq) and the Information Practices Act of 1977 (IPA) (Civil
Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The
requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate
the processing of this form. The failure to provide all or any part of the requested information may delay
processing of this form. No disclosure of personal information will be made unless permissible under Article 6,
Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to
inspect all personal information in any record maintained on the individual by an identifying particular.
PERMISSION IS REQUESTED TO ENCROACH ON THE STATE HIGHWAY RIGHT OF WAY AS FOLLOWS:
Please call 1-866-ADOPTAHWY for assistance in completing this form.
APPLICATION TYPE (Check One)
New Adoption
Adoption Renewal
Waiting List Placement
ADOPTION TYPE
1
Litter Removal
Seeding Tree and Shrub Planting
1
Graffiti Removal
Wildflower Planting and Vegetation Control
1
1
Vegetation Control
"Spot" Wildflower Planting
("Spot" adoption participants receive no sign)
Recognition Panel Replacement (Contractors only. Panels must be approved by the Department.)
Other, describe
NOTE: Applications for new adoptions and adoption renewals will not be processed until required support documents have been received.
1 Plans and schedules are required. If herbicides will be used, a Pest Control Recommendation is required and the applicator must submit proof of appropriate licensing or certification by the Department of
Pesticide Regulation.
ADOPTION SITE LOCATION
COUNTY
ROUTE
POST MILE RANGE
DIRECTION(S)
North Bound
South Bound
East Bound
West Bound
BEGINNING POST MILE DESCRIPTION (Landmark, cross street, etc.)
END POST MILE DESCRIPTION (Landmark, cross street, etc.)
APPLICANT INFORMATION
DOUBLE PERMIT
ORGANIZATION/BUSINESS NAME
Check if applicant is a contractor
PRIMARY CONTACT
TITLE
(Unless otherwise notified, Caltrans assumes that the primary contact is the group's safety leader)
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
ALTERNATE PHONE NUMBER
FAX
E-MAIL
ALTERNATE CONTACT (Required)
ALTERNATE CONTACT'S PHONE NUMBER
Check if alternate contact
is the groups safety leader
WORK WILL BE PERFORMED BY
Volunteers over the age of 18
Volunteers over the age of 16
Hired Contractor (name)
AUTHORIZED SIGNATURE
The undersigned agrees that work will be done in accordance with Caltrans rules and regulations and subject to inspection and approval.
The Adopt-A-Highway Program and it's courtesy signs are not a forum for advertisement or public discourse.
SIGNATURE OF PRIMARY CONTACT
DATE
FM 90 1180 M
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PERMIT NO.
ADOPT-A-HIGHWAY PERMIT APPLICATION
TR-0103 (REV 09/2009)
DIST/CO/RTE/PM
FOR CALTRANS USE
(Date Received)
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (Section 552, et. seq) and the Information Practices Act of 1977 (IPA) (Civil
Code Sections 1798, et seq.), notice is hereby given for the request of personal information by this form. The
requested personal information is voluntary. The principal purpose of the voluntary information is to facilitate
the processing of this form. The failure to provide all or any part of the requested information may delay
processing of this form. No disclosure of personal information will be made unless permissible under Article 6,
Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper identification, to
inspect all personal information in any record maintained on the individual by an identifying particular.
PERMISSION IS REQUESTED TO ENCROACH ON THE STATE HIGHWAY RIGHT OF WAY AS FOLLOWS:
Please call 1-866-ADOPTAHWY for assistance in completing this form.
APPLICATION TYPE (Check One)
New Adoption
Adoption Renewal
Waiting List Placement
ADOPTION TYPE
1
Litter Removal
Seeding Tree and Shrub Planting
1
Graffiti Removal
Wildflower Planting and Vegetation Control
1
1
Vegetation Control
"Spot" Wildflower Planting
("Spot" adoption participants receive no sign)
Recognition Panel Replacement (Contractors only. Panels must be approved by the Department.)
Other, describe
NOTE: Applications for new adoptions and adoption renewals will not be processed until required support documents have been received.
1 Plans and schedules are required. If herbicides will be used, a Pest Control Recommendation is required and the applicator must submit proof of appropriate licensing or certification by the Department of
Pesticide Regulation.
ADOPTION SITE LOCATION
COUNTY
ROUTE
POST MILE RANGE
DIRECTION(S)
North Bound
South Bound
East Bound
West Bound
BEGINNING POST MILE DESCRIPTION (Landmark, cross street, etc.)
END POST MILE DESCRIPTION (Landmark, cross street, etc.)
APPLICANT INFORMATION
DOUBLE PERMIT
ORGANIZATION/BUSINESS NAME
Check if applicant is a contractor
PRIMARY CONTACT
TITLE
(Unless otherwise notified, Caltrans assumes that the primary contact is the group's safety leader)
ADDRESS
CITY
STATE
ZIP CODE
PHONE NUMBER
ALTERNATE PHONE NUMBER
FAX
E-MAIL
ALTERNATE CONTACT (Required)
ALTERNATE CONTACT'S PHONE NUMBER
Check if alternate contact
is the groups safety leader
WORK WILL BE PERFORMED BY
Volunteers over the age of 18
Volunteers over the age of 16
Hired Contractor (name)
AUTHORIZED SIGNATURE
The undersigned agrees that work will be done in accordance with Caltrans rules and regulations and subject to inspection and approval.
The Adopt-A-Highway Program and it's courtesy signs are not a forum for advertisement or public discourse.
SIGNATURE OF PRIMARY CONTACT
DATE
FM 90 1180 M
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
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