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Get PA CS-4171 2019-2024

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. These files must be available for inspection and verification by a Department Representative for a period of not less than THREE years from the date of the last shipment. 6. 3 for additional guidance in completing this Form* COUNTY LR/SR SEC/SEG* ECMS To be completed by the party that will ship the material to the construction project otherwise leave blank. NAME OF MANUFACTURER FABRICATOR COATER PRECASTER OR PRODUCER - Check appropriate box manufactured fabricated coated precasted or produced as appropriate. If a single company performs more than one operation e*g* a company manufactures and coats guiderail more than one box may be checked* - Also provide the name and the supplier code of the manufacturer fabricator coater or precaster of the material listed in Bulletin 15 or the name and the supplier code of the Producer of material listed in Bulletin 14 41 or 42. MEETS SPECIFICATION REQUIREMENTS SHIPPED TO List the name of the company that material is being shipped to. LOT NUMBER QUANTITY DESCRIPTION OF MATERIAL CHECK THIS BLOCK IF YOUR PRODUCT CONTAINS IRON OR STEEL VENDOR CLASSIFICATION CHECK ONE BLOCK ONLY If you are a Manufacturer Fabricator Coater or Precaster listed in Bulletin 15 or a Producer listed in Bulletin 14 41 or 42 check block 1. If you are a Distributor Supplier or Private Label Company of Bulletin 15 items check block 2. - These categories are not eligible for listing in Bulletin 15 however you may provide material for PennDOT projects on condition that the material being shipped is listed in Bulletin 15. CERTIFICATION REQUIREMENTS Name Title Date Company Name and Signature Enter the required information and sign the Certificate of Compliance form* COMPLETE LINE 9 ONLY IF YOU CHECKED BLOCK 2 ON LINE 7 OTHERWISE LEAVE BLANK List company that sold the material to you. uCOUNTY uLR/SR uSEC/SEG uECMS I / WE hereby certify that the material 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 Code Publication 408 Section s AASHTO ASTM Federal or other designation The material listed below is being shipped to LOT NO.

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