L listed on line 5 was: If a single company performs more than one operation (e.g., a company manufactures and coats guiderail), more than one box may be checked. r Manufactured r Fabricated r Coated r Precasted r Produced By (Name of Manufacturer, Fabricator, Coater, Precaster or Producer) and the party listed above certifies that the material(s) on line 5 meets the requirements of (Supplier.
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How to fill out the Penndot Cs 4171 online
Completing the Penndot Cs 4171 form is an essential step in ensuring compliance for material shipments to construction projects. This guide will provide you with a clear, step-by-step approach to efficiently and accurately fill out the form online.
Follow the steps to successfully complete the Penndot Cs 4171 form.
- Click the ‘Get Form’ button to obtain the form and open it in the editor.
- In the COUNTY, LR/SR, SEC/SEG, and ECMS# section, input the relevant details if you are the party shipping the material. If this does not apply, leave this section blank.
- Under the NAME OF MANUFACTURER, FABRICATOR, COATER, PRECASTER OR PRODUCER section, check the appropriate box that accurately describes the role of your company regarding the material. If applicable, enter the company name and the supplier code.
- Indicate whether the material meets specification requirements. This is also to be completed by the party shipping the material.
- In the SHIPPED TO section, provide the name of the company that will receive the material being shipped.
- Complete the LOT NUMBER, QUANTITY, DESCRIPTION OF MATERIAL section with accurate information about the material being shipped.
- Check the block if your product contains iron or steel. This is mandatory for compliance.
- In the VENDOR CLASSIFICATION section, choose the appropriate block: Block #1 for Manufacturers, Fabricators, Coaters, or Precasters listed in Bulletin #15, or Block #2 for Distributors, Suppliers, or Private Label Companies.
- Fill in the CERTIFICATION REQUIREMENTS section with your NAME, TITLE, DATE, COMPANY NAME, and sign the form.
- If you checked Block #2 in line #7, complete line #9 by listing the company name that sold the material to you. If Block #2 was not selected, leave this blank.
- Review and ensure all sections are accurately completed. Save your changes, then download or print the completed form for your records. A copy must be kept with the material shipment.
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State Highway Agency (SHA) The terms “State” or “PennDOT” should be considered equivalent to State highway agency.
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I certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania that require filing confidential information and documents differently than non-confidential information and documents.
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