TEXAS DEPARTMENT OF PUBLIC SAFETY
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Texas Department of Public Safety
Motor Carrier Bureau
Corrected Violations/Safety Rating Change Request
Please Check Box:
This is a request to upgrade our current safety rating. I am submitting this information to advise the Texas Department of Public Safety of the corrective actions our company has made and respectfully request an investigator to re-evaluate our company.
|CP Number |USDOT Number |TXDOT Number |Date of Original Review |
| | | | |
|Legal Name |Mailing Address |Contact Name & Telephone Number |
| | | |
Current Proposed (or Final) Rating (as a result of the most recent review)
Violations from Original Review that have been corrected (Attach extra pages if necessary)
|1. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
|Corrective Actions Taken: |
|2. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
|Corrective Actions Taken: |
|3. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
|Corrective Actions Taken: |
|4. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
|Corrective Actions Taken: |
|5. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
|Corrective Actions Taken: |
|6. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
Corrective Actions Taken: _________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
|7. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
Corrective Actions Taken: _________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
|8. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
Corrective Actions Taken: _________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
|9. Violation No(Part B violations, first | |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
Corrective Actions Taken: _________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
|10. Violation No(Part B violations, first| |Primary Citation (Part B violations, second | |Evidence Attached: | |
|box) | |box) | | | |
Corrective Actions Taken: _________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If applicable, address the following additional safety issues:
Factor 6 Accident Rate
Performance Data (OOS%)
|The corrective actions listed above have been taken. |MCB USE Only |
| |Upgrade Request: Approved _____ Denied _____ |
| |If Denied, Reason |
|Carrier Signature, Title |Reviewed by Date |
|Date |Approved by Date |
| |Comments |
| |CAP Letter: Date Logged _________ Date Filed |
|Supervisor Signature, Title |Processed by (initials) _________ |
| | |
| | |
|Date & Time | |
This form may be e-mailed to [Area supervisor]@dps. or faxed to (Area fax number].
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(512) 424-2335
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