CS-4171 12-15 www. penndot. gov CERTIFICATE OF COMPLIANCE INSTRUCTIONS Refer to Publication 2 Project Office Manual Section B. Only Form CS-4171 is required. r Unidentified Steel Attach supporting documentation including invoices bills of lading and mill test reports that positively identify that the steel was melted and manufactured in the United States. Company Name IN ADDITION Private Label Companies who complete the Certificate of Compliance form CS-4171 must identify the true manufacturer Line 2 and the approved material Line 5 as it is listed in Bulletin 15 under that manufacturers listing. After completing the Certificate of Compliance form CS-4171 maintain the original at your company s location. A copy of the Certificate of Compliance form must accompany your material shipment to its next destination. Also if you receive material shipments from other companies related to PennDOT projects the accompanying Certificate of Compliance forms must be kept on file at your location. Th....
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How to fill out the PA CS-4171 online
The PA CS-4171 is a Certificate of Compliance form used in the shipping of approved materials for Pennsylvania Department of Transportation projects. This guide will provide you with clear and concise steps to successfully complete this form online, ensuring compliance with regulations.
Follow the steps to accurately complete the PA CS-4171 form.
- Press the 'Get Form' button to access the PA CS-4171 form and open it in your preferred editor.
- Enter the county, lr/Sr, Sec/SeG, and ecmS# at the top of the form. This information pertains to the project location. If this is not known, you may leave it blank as it will be filled by the project contractor.
- Identify the manufacturer, fabricator, coater, precaster, or producer of the material. Check the relevant boxes to indicate the operations performed such as 'manufactured', 'fabricated', 'coated', 'precasted', or 'produced'. Include the supplier code for the entity.
- List the specifications that the product meets. This may include publication 408 or any relevant designations like aaSHto or aStm. Be precise in documenting this information.
- Provide the name of the company to which the material is being shipped. It is important to ensure that the information is accurate.
- Document the lot number, quantity, and detailed description of the material being shipped, as noted in PennDOT Bulletin # 15 or other relevant bulletins.
- If your product contains iron or steel, check the appropriate box and fill out the related sections to indicate whether the product is made of 100% U.S. steel or contains minimal foreign steel, following the requirements of Act 3 and Buy America.
- Complete the vendor classification section by checking the applicable box based on your role as a manufacturer, coater, fabricator, or distributor. Fill in your name, title, and company name accurately.
- Sign and date the certification section of the form. Ensure that you retain the original document at your location and include a copy with the material shipment.
Complete your documents online to ensure a smooth compliance process.
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