Form Cs-4171b - Certificate Of Compliance For Daily Bituminous Mixtures

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CERTIFICATE OF COMPLIANCE
CS-4171B (2-16) Formerly TR-465
FOR DAILY BITUMINOUS MIXTURES
Plant: _______________________________________________________________________________________________
Location: ____________________________________________________________________________________________
Plant Code: __________________________________________________________________________________________
Job Mix Formula (Year-Number): ___________________________ Material Class: _________________________________
ESALS: __________________________ SRL: __________________________ PG Grade: __________________________
Publication 408, Section: _________________
Consigned to:
PennDOT Maintenance: _________ County: _______________________________ P.O. No. ______________________
Contractor: ___________________________________________ S.R.: _______________ Section: _________________
Group / P.O.C. No.: _______________________________________ ECMS No.: __________________________________
Municipality: __________________________________________ County: ______________________________________
Wearing Course: _______________________ Binder Course: ___________________ Base Course: ___________________
Tons Shipped: _______________________________ Daily AASHTO T209 Density: __________________________________
Air Voids
VMA
Test Results
%AC
Pass #8
Pass #200
Specimen #1
Specimen #2
Specimen #1
Specimen #2
Daily No. 1
Daily No. 2
Daily No. 3
Daily Avg.
Running Avg. of 5
Please select the Payment Factor percentage below, based on Pub 408 Sec. 409.4(a) Table H:
100% Payment Factor: The material as listed above shipped on this date conforms fully with the specification
requirements of the Pennsylvania Department of Transportation. Our records, attesting to this statement, are
open for inspection by a Department Representative for not less than THREE years from the date of shipment.
85% Payment Factor: The material as listed above shipped on this date does not conform to the certification
tolerances for 100% pay as listed in Pub 408 Sec. 409.2(e) Table A. A reduced pay factor has been applied and QC
test results are being forwarded to the Inspector-in-Charge. Our records attesting to this statement are open for
inspection by a Department Representative for not less than THREE years from the date of shipment.
Defective Pavement: The material as listed above shipped on this date does not conform to the certification
tolerances for 100% pay as listed in Pub 408 Sec. 409.2(e) Table A. QC test results are being forwarded to the
Inspector-in-Charge which indicate material must be removed and replaced or accepted at 50% CUP with District
Executive approval in writing. Our records attesting to this statement are open for inspection by a Department
Representative for not less than THREE years from the date of shipment.
Name (print): ________________________________________________ Title: ____________________________________
Signature: _______________________________________________________ Date Shipped: _______________________

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