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PLEASE COMPLETE AND RETURN WITH APPLICATION

Contact Person:

Is the junkyard visible from Right of Way?

Distance from Right of Way

Width of junkyard

City:

Email Address:

Junkyard Owner Name: Telephone Number:

Street Address: State: Zip Code:

NEW JUNKYARD INFORMATION SHEET

Junkyard Name:

MISSOURI DEPARTMENT OF TRANSPORTATION

Junkyard Address: City: State: Zip Code:

If yes, approximate number

If yes, type

If yes, type

If yes, typeLiquid or solid waste

Old or scrapped batteries

Old or scrapped tires

Automotive parts

Vehicles Yes / No

Yes / No

( Owner Signature ) Date

Old or scrapped metals

Old or scrapped plastics

Junkyards, pursuant to Sections 226.650 to 226.720 RSMo, and understand I must comply with those provisionsI hereby certify that all the information above is true and correct to the best of my knowledge, and that I am familiar with the Missouri Control of

Depth of junkyard

Type of screening

Yes / No

Yes / No

Yes / No

Yes / No

Yes / No

If yes, approximate total number Number running

If yes, approximate number

If yes, approximate number

Additional forms and information available at http://www.modot.org/business/Outdoor_Advertising

Our mission is to provide a world-class transportation experience that delights our customers and promotes a prosperous Missouri.

Revised 08/20

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