FORM M-233ST State Form 944 (R7 / 1-08) Indiana Department of Revenue Fee: $42.50 Special Weight Single Trip Applicaton FEIN/SSN# Name of Transporting Company: Telephone Number Street Address City: Start Date Start Time State Plated Make of Tractor License Plate Number State: Fax Number ModelYear: Full Vehicle Identification Number Vehicle Type Truck-Trailer Overall Length: ZIP: Legal Overall Width: Legal Tractor-Trailer Other Towed Overall Height: Legal Allowable Weights: Single axle weight must not exceed 18,000 pounds per axle; no axle in any axle combination may exceed 13,000 pounds per axle, with the exception of one tandem group that may weigh 16,000 pounds per axle or a total of 32,000 pounds. The maximum gross weight must not exceed 134,000 pounds for routes 1-21 below and 90,000 lbs for route 22 below; axle spacings may not be less than 3'6" between each axle in an axle combination; axle spacings may not be less than 8 feet between each axle or axle combination; weight per inch width of tire measured between flanges of rim shall not exceed 800 pounds. The provisions on the reverse side of this form are incorporated by reference into this permit and are as fully binding upon the permittee as if they had appeared on the face of this permit. This permit is void or invalid if the provisions are omitted from the revise side of this form or are not attached. The Permit is Valid Over State Roads: (1) US 41, from 129th Street in Hammond to SR 312, (2) Highway 312, from Highway 41 to State Road 912, (3) Highway 912, from Michigan Avenue in East Chicago to the U.S. 20 interchange, (4) Highway 20, from Clark Road in Gary to Highway 39, (5) Highway 12, from one-fourth (1/4) mile west of the Midwest Steel entrance to Highway 249, (6) Highway 249, from Highway 12 to Highway 20, (7) Highway 12, from one and one-half (1 1/2) miles east of the Bethlehem Steel entrance to Highway 149, (8) Highway 149, from Highway 12 to a point thirty-six hundredths (.36) of a mile south of Highway 20, (9) Highway 39, from Highway 20 to the Michigan state line, (10) Highway 20, from Highway 39 to Highway 2, (11) Highway 2, from Highway 20 to Highway 31, (12) Highway 31, from the Michigan state line to Highway 23, (13) Highway 23, from Highway 31 to Olive Street in South Bend, (14) Highway 35, from South Motts Parkway thirty-four hundredths (.34) of a mile southeast to the point where Highway 35 intersects with the overpass for Highway 20/Highway 212, (15) State Road 249 from U.S. 12 to the point where State Road 249 intersects with Nelson Drive at the Port of Indiana, (16) State Road 912 from the 15th Avenue and 169th Street interchange one and six hundredths (1.06) miles north to the U.S. 20 interchange, (17) U.S. 20 from the State Road 912 interchange three and seventeen hundredths (3.17) miles east to U.S.12, (18) U.S. 6 from the Ohio State line to State Road 9, (19) U.S. 30 from Allen County/Whitley County Line Road (also know as County Road 800 East) to State Road 9, (20) State Road 9 from U.S. 30 to U.S. 6, (21) State Road 39 from Interstate 80 to U.S. 20, (22) State Road 3 north from U.S. 6 to U.S. 20, U.S. 20 west from State Road 3 to State Road 9, State Road 9 north from U.S. 20 to the Michigan state line. No other routes, including detours, are authorized by this permit under any condition. This permit is valid only for transporting commodities under the company name shown above, and if signed by both an authorized company owner or officer, and driver. The driver’s signature attests to the fact that the description of the vehicle is accurate and that the provisions on the reverse side of this permit have been read and understood by the driver. Under the penalty of perjury, I have examined this permit, and to the best of my knowledge and belief, it is true, complete and correct. I also understand that all provisions of the Transporting Agreement apply in full force. Driver's Signature Company Owner or Responsible Officer Date Driver's Signature Date American LegalNet, Inc. www.FormsWorkflow.com