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C_] <br />r <br />4W <br />INDIAN RIVER COUNTY <br />ADOPT--A-ROADWAY <br />LITTER REMOVAL REPORT FORM <br />Name of Organization/Group <br />Name of Adopt -A -Roadway Coordinator <br />Address <br />Phone No.( ) <br />DOT District IV <br />Indian River County Traffic Engineer(Representative) <br />Address <br />Phone No. ( } <br />Date of Clean-up , 19 <br />Roadway Name <br />Number of Miles Adopted <br />Number of Volunteers <br />Number of Volunteer Hours <br />(This number should be number of volunteers x how s = Total) <br />Amount of litter collected: <br />Trash Recyclable <br />1. No. of Bags <br />2. Weight of Bags* <br />Check one: Actual Wt. Ext. Wt. <br />3. No. of cubic Yards <br />(Optional) <br />*If scales are not available, please estimate weight. <br />Please attach a copy of map delineating the section of highway <br />adopted. This map need only be attached with the first litter <br />clean-up report form.(Map(s) will not be provided by Indian River <br />County Traffic Engineering Office) <br />Injury Report: Report in detail on the back of this page any <br />injuries or emergencies that occurred during the litter removal. <br />period. <br />'dopt.con oB-26-94 <br />--5- <br />