HomeMy WebLinkAboutRAM 081 01 R A72 Extruded Concrete Curb - ResponseRequest for Approval of Material
Contract Number FA Number SR Date
Section / Title of Project County
Contractor Subcontractor
For assistance in completing, see Instructions and Example
Bid
Item No.
Material or
Product/Type
Name and Location of Fabricator,
Manufacturer or Pit Number
Specification
Reference
PE/QPL
Code
Hdqtr./QPL
Code
Acceptance Action Codes for use by Project Engineer and State Materials Laboratory
1. Acceptance Criteria:
2. Acceptance Criteria:
3. Acceptance Criteria:
4. Acceptance Criteria:
5. Acceptance Criteria:
6. Acceptance Criteria:
7. Acceptance Criteria:
8. Source Approved:
Acceptance based upon 'Satisfactory' Test Report for samples of materials to be incorporated into project.
Mfg. Cert. of Compliance for 'Acceptance' prior to use of material.
Catalog Cuts for 'Acceptance' prior to use of material.
Submit Shop Drawings for 'Approval' prior to fabrication of material.
Only 'Approved for Shipment', 'WSDOT Inspected' or 'Fabrication Approved Decal' material shall be used.
Submit Certificate of Materials Origin to Project Engineer Office.
Request Transmitted to State Materials Laboratory for Approval Action.
9. Approval Withheld:
10. Approval Withheld:
11. Miscellaneous Acceptance Criteria.
Remarks:
Submit samples for preliminary evaluation.
Project Engineer Distribution State Materials Engineer Distribution
General FileContractor
DOT Form 350-071 EF
Revised 12/2012
Project Engineer Date State Materials Engineer Date
RAM #
Region Operations Engineer
Region Materials
State Materials Lab
Fabrication Inspection
Signing Inspection
Other
For WSDOT Use Only
M/S 47365
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.
Catalog Cut Approved Yes No
CAG-15-134 STPUL-1131(002)
Logan Ave N - Airport Way to N 6th Street - Project King
Johansen Excavating, Inc.