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MISSOURI DEPARTMENT OF TRANSPORTATION
MOTOR CARRIER SERVICES
830 MoDOT DRIVE
JEFFERSON CITY, MO 65102-0270
PHONE: 1-800-877-8499 FAX: 573 751-7408
EMAIL: CONTACTMCS@MODOT.MO.GOV
SUPERLOAD ROUTE SURVEY AND
EMERGENCY PLAN FORM
USDOT NUMBER:
APPLICATION NUMBER:
Permittee Name (print):
Permittee Address (print Street/PO Box, City, State, Zip):
Permitted Load:
Number of Axles:
Load Width:
Load Length:
Load Height:
Gross Weight:
Overall Width:
Overall Length:
Overall Height:
Trip Mileage:
Height Pole Setting (if load exceeds 15’6”)
DRIVER EMERGENCY CONTACT NUMBER (keep available in case an incident occurs)
OWNER NAME AND ADDRESS
TITLE
TELEPHONE NUMBER
DRIVER NAME AND ADDRESS
TITLE
CELL PHONE NUMBER
This route survey form is only valid when the route described on page 2 of the form will allow safe travel and
sufficient clearance for the dimensions described on page 1 of this form. The route survey shall be completed no
more than 14 days prior to the permit start date. All non-state roads and highways must be shown for route
continuity, but the requirement to include such roads on the form does not constitute authorization by MoDOT for
use of such non-state roads and highways by the Permittee.
FALSE INFORMATION IS PROHIBITED ON THIS ROUTE SURVEY FORM AND SHALL
AUTOMATICALLY INVALIDATE THE PERMIT. THIS COMPLETED DOCUMENT MUST BE
SUBMITTED BY THE PERMITTEE TO MOTOR CARRIER SERVICES BEFORE A PERMIT
SHALL BE ISSUED.
I declare under penalty of perjury that the statements made on this document are true and complete to the best of my knowledge.
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Permittee Signature (Required) Date
SUPERLOAD ROUTE SURVEY AND
EMERGENCY PLAN FORM
USDOT NUMBER:
APPLICATION NUMBER:
Operations Manager:
Name: ____________________________________ Contact #: ________________________________
Safety Operations:
Name:____________________________________ Contact #: _________________________________
(Routing must be complete, including but not limited to, all city streets and/or county roads for the proposed line of
travel.) Route verified to the latest restrictions report for limitations that may affect the movement of this vehicle/load -
http://maps.modot.mo.gov/mcm/MotorCarriersMap.html
MISSOURI START ROUTE:
MISSOURI END ROUTE:
Detailed proposed routing (include any grade conflicts or clearance issues - attach additional routing page(s) if needed):
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Fax completed form to 573-751-7408
List tow/wrecker/recovery service information:
Company: ______________________________ Contact #: ______________________________
My overall height exceeds 17’ high and I have contacted and obtained letters from all proper utility
companies to move all overhead structures belonging to appropriate entity.
UTILITY COMPANY LETTERS ATTACHED IF OVERALL HEIGHT EXCEEDS 17’0”.
(to move signs, arm masts etc)
My overall height exceeds 16’ high and I have contacted all utility and cable companies along
proposed route.
My overall height exceeds 16’ high and I have obtained a licensed contractor/bucket truck to travel
with load on entire/approved route.
Company: _____________________ ________ Contact #: ________________________________
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