HomeMy WebLinkAbout26 00 00-5-2 - Signal Poles and Bolts_SKANSKA REVIEWED (003)
Request for Approval of Material
Contract Number
221110
FA Number SR
Date
Section / Title of Pr
Traffic Signal-Lind Ave SW and SW 19th Street
County
King
Contractor
Ceccanti
Subcontractor
West Coast Signal
This form shall be completed prior to submittal. If this form is not complete at time of
submittal it may be returned for information that was omitted.
For assistance in completing, see Instructions and Example
Project Engineer Distribution State Materials Engineer Distribution
Contractor Region Materials General File Signing Inspection
Region Operations Engineer
Fabrication Inspection
DOT Form 350-071 EF Revised 12/2012
State Materials Lab
M/S 47365
Other
For WSDOT Use Only
RAM #
Bid
Item No.
Material or
Product/Type
Name and Location of Fabricator,
Manufacturer or Pit Number
Specification
Reference
PE/QPL
Code
Hdqtr./QPL
Code
3A Traffic Signal Mast Arm Ameron – Tulsa, OK 9-29.6(1)
Project Engineer Date State Materials Engineer Date
Acceptance Action Codes for use by Project Engineer and State Materials Laboratory
1. Acceptance Criteria: Acceptance based upon 'Satisfactory' Test Report for samples of materials to be incorporated into project.
2. Acceptance Criteria: Mfg. Cert. of Compliance for 'Acceptance' prior to use of material.
3. Acceptance Criteria: Catalog Cuts for 'Acceptance' prior to use of material. Catalog Cut Approved Yes No
4. Acceptance Criteria: Submit Shop Drawings for 'Approval' prior to fabrication of material.
5. Acceptance Criteria: Only 'Approved for Shipment', 'WSDOT Inspected' or 'Fabrication Approved Decal' material shall be used.
6. Acceptance Criteria: Submit Certificate of Materials Origin to Project Engineer Office.
7. Acceptance Criteria: Request Transmitted to State Materials Laboratory for Approval Action.
8. Source Approved:
9. Approval Withheld: Submit samples for preliminary evaluation.
10. Approval Withheld:
11. Miscellaneous Acceptance Criteria.
Remarks:
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