Highway-Rail HSIP Application (Rev. 5/31/09)
Virginia Department of Transportation Project: ______
Highway Safety Improvement Program Applicant: ______
Highway-Rail Grade Crossing Safety Program Rail file______- ______
Date Rec’d: ______(for office use only)
Highway-Rail Grade Crossing Safety Program FY10-11
Project Application
Please use a separate application form for each location submitted. FY 2010 applications will be received from May 30, 2009 to September 5th, 2009.
An electronic version of this form needs to be sent to in addition to a signed hardcopy.
1. Applicant Name and Mailing Address:
2. Project Sponsor Name and Title:
Telephone Number: () - Ext.
Fax Number: () -
An electronic version of this form needs to be sent to in addition to a signed hardcopy.
3. Specific Location of Proposed Grade Crossing Improvement Project - Sketch, Map or Photo of Project Limits Attached:
DOT AAR No.:
County/City Route(s)/Street(s)
Termini:
(Please use information provided on the inventory listing)
4. Recommended Type of Grade Crossing Improvement:
*NOTE: If signal upgrades and surface improvements are needed at an individual location, a separate application must be submitted for each improvement type. Please see the application process in Chapter 5 of the HSIP FY09-10 Guidelines for more information.
An electronic version of this form needs to be sent to in addition to a signed hardcopy.
5. Estimated Project Costs:
Total
6. Additional Information:
(ADT, School Bus Traffic, Hazardous Material Transport Vehicle Crossing and Counts, etc.)
An electronic version of this form needs to be sent to in addition to a signed hardcopy.
7. Signature of Applicant:
Date:
NOTE: a locality resolution is required upon notification of program approval for secondary road and urban projects.
Technical Assistance - Please feel free to contact the Highway/Rail Safety Section at (804) 786-2822 if there are any questions.
Mailing Addresses:
VDOT Districts: Cities/Towns: Counties:
Mr. Ray Khoury, P. E. Mr. Ray Khoury, P.E. Resident Engineers are requested to submit
State Traffic Engineer State Traffic Engineer applications within their residency through the
Virginia Department of Transportation Virginia Department of Transportation District Administrator and forward them to:
1401 East Broad Street 1401 East Broad Street State Traffic Engineer
Richmond, Virginia 23219 Richmond, Virginia 23219 Traffic Engineering Division
An electronic version of this form needs to be sent to in addition to a signed hardcopy.