EXHIBIT A (PAGE 2)
KEEP CHARLOTTE BEAUTIFUL
ADOPT-A-ROAD PROGRAM
PRODUCTIVITY REPORT FORM
GROUP NAME:________________________________________ .
ROAD ASSIGNED: _____________________________________
FROM: ______________________________ TO: _______________________ .
LITTER REMOVAL INFORMATION
LITTER REMOVAL DATE: _______________________________________________________
NUMBER OF VOLUNTEERS THAT REMOVED LITTER: _____________________________
NUMBER OF HOURS WORKED TO REMOVE LITTER: ______________________________
TOTAL NUMBER OF HOURS WORKED TO REMOVE LITTER: _______________________
NUMBER OF TRASH BAGS RECEIVED: ___________________________________________
NUMBER OF TRASH BAGS FILLED DURING LITTER REMOVAL: ___________________
ESTIMATED POUNDS OF TRASH REMOVED: ______________________________________
NUMBER OF TRASH BAGS RETURNED: ___________________________________________
LARGE, HEAVY OR HAZARDOUS ITEMS THAT IT IS REQUESTED THE COUNTY PICK UP:
ITEM LOCATION (LANDMARK)
___________________________ ________________________________
___________________________ ________________________________
GROUP INFORMATION
REPORT PREPARED BY: _________________________________________________________
(PLEASE PRINT)
SIGNATURE: ____________________________________________________________________
AUTHORIZED REPRESENTATIVES SIGNATURE
CONTACT NUMBER: ____________________________________________________________