Form Cs-4171 - Certificate Of Compliance
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1
2CERTIFICATE OF COMPLIANCE
CS-4171 (12-15)
www penndot gov
INSTRUCTIONS
Refer to Publication 2, Project Office Manual, Section B.6.3 for additional guidance in completing this Form.
1.
COUNTY, LR/SR, SEC/SEG. ECMS#
To be completed by the party that will ship the material to the construction project, otherwise leave blank.
2.
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.
- To be completed by the party that is shipping approved material to the next destination.
3.
MEETS SPECIFICATION REQUIREMENTS
To be completed by the party that is shipping approved material to the next destination.
4.
SHIPPED TO
List the name of the company that material is being shipped to.
5.
LOT NUMBER, QUANTITY, DESCRIPTION OF MATERIAL
To be completed by the party that is shipping approved material to the next destination.
6.
CHECK THIS BLOCK IF YOUR PRODUCT CONTAINS IRON OR STEEL
To be completed by the party that is shipping approved material to the next destination.
7.
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.)
8.
CERTIFICATION REQUIREMENTS, Name, Title, Date, Company Name, and Signature
Enter the required information and sign the Certificate of Compliance form.
9.
COMPLETE LINE # 9 ONLY IF YOU CHECKED BLOCK # 2 ON LINE # 7, OTHERWISE LEAVE BLANK
List company that sold the material to you. (Company Name)
IN ADDITION:
2. & 5.
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.
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