Form Cs-4171 - Certificate Of Compliance Page 2
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1
2CERTIFICATE OF COMPLIANCE
CS-4171 (12-15)
www penndot gov
1.
uCOUNTY:_________________________ uLR/SR:____________ uSEC/SEG:____________ uECMS#:____________
(u - To be completed by the party that will ship the material to the project, otherwise leave blank.)
2.
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.
Manufactured
Fabricated
Coated
Precasted
Produced
r
r
r
r
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By_____________________________________________________________
________________________________
(Name of Manufacturer, Fabricator, Coater, Precaster or Producer)
(Supplier Code)
3.
and the party listed above certifies that the material(s) on line 5 meets the requirements of
Publication 408, Section(s) __________________________________________________________________________
AASHTO, ASTM, Federal or other designation ____________________________________________________________
4.
The material listed below is being shipped to:______________________________________________________________
(Company Name)
5.
LOT NO.
QUANTITY
APPROVED MATERIAL AS LISTED IN BULLETIN # 14 or 15
BULLETIN # 41 or 42 PRODUCERS, LIST HMA / PCC JMF.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
6.
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CHECK HERE IF YOUR PRODUCT CONTAINS IRON OR STEEL (AND check one of the following boxes, as
appropriate.) I / WE certify the material identified above conforms with Section 106.01 of Publication 408 as indicated
below.
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‘Identifiable Steel’ or Fabricated Structural Steel (Section 1105). Either Steel products that contain permanent markings
that identify that the material was melted and manufactured in the United States or which have received in-plant
inspection by the Department or a Department representative where verification of Mill Test reports was performed to
verify conformance with the PA Steel Procurement Act. Only Form CS-4171 is required.
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‘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.
All manufacturing processes including coatings application (e.g. epoxy, galvanizing, or painting) have occurred in the
United States and we are maintaining copy(s), in our files in accordance with Section106.03(b)3. Note: While coating
materials themselves are not covered by Buy America, the application of these materials on steel or iron must occur in
the United States.
7.
VENDOR CLASSIFICATION (CHECK ONE BLOCK ONLY) -
#1 Manufacturer, Fabricator, Coater, Precaster
Distributor, Supplier or *Private Label Company
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#2
Listed in Bulletin # 15, or Producer Listed in
Not Listed in Bulletin # 15.
Bulletin # 14, 41 or 42
Also, complete line 9
I certify that the above statements are true and to the
I certify that the material being supplied is one and the same as
best of my knowledge, fairly and accurately describe
provided to us by the manufacturer listed on this document and
the product(s) listed.
quantities listed above are accurate.
8.
NAME (print) : ____________________________________________ TITLE:__________________________________
COMPANY NAME : ________________________________________________________________________________
SIGNATURE : ______________________________________________________ DATE: ________________________
By Responsible Company Official (QC Staff only if you checked block #1 on line 7)
9.
List company that sold you the material(s) documented above: ______________________________________________
(Complete if you checked Block # 2 on line # 7, otherwise leave blank.)
(Company Name)
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