Fill - Free fillable 16312 Superload Route Survey & Emergency Plan PDF form

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”)

Insurance Company Name: _________________________________ Policy Number: ________________________________________

Policy Expiration Date: ____________________________ Automobile Liability/General Aggregate Coverage Amount: $____________________

**SUPERLOADS ARE REQUIRED TO HAVE A MINIMUM OF $2 MILLION OF COVERAGE**

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.

_______________________________________________________________________________________________

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):

__________________________________________________________________________________________________

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 #: ________________________________

Fill Online, Printable, Fillable, Blank 16312 Superload Route Survey & Emergency Plan Form

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Fillable 16312 Superload Route Survey & Emergency Plan

Fill Online, Printable, Fillable, Blank 16312 Superload Route Survey & Emergency Plan Form

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