CS-4171 (3-19)
certificate of compliance
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:
Ifasinglecompanyperformsmorethanoneoperation(e.g.,acompanymanufacturesandcoatsguiderail),morethanoneboxmaybechecked.
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: ________________________________________________________________________
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(Company Name) |
5. |
lot no. |
QUantitY |
approVeD materialaS liSteD in pennDot BUlletin |
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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r cHecK Here if YoUr proDUct containS iron or Steel. I certify the material identified above conforms to Sections 106.01 and 106.10(a) of Publication 408.
cHecK one of tHe tWo BoXeS: |
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r Product is 100% US steel. |
r Product contains minimal foreign steel in accordance with Act 3 and Buy America. |
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attach form cS-4171S with receipts or invoices. |
cHecK tHe BoX tHatapplieS to YoUr proDUct:
r‘Identifiable Steel’ - Steel products that contain permanent markings that identify that the material was melted and manufactured in the United States. only form cS-4171 is required.
rSteel Products and Products Containing Steel with In-Plant Inspection by the Department or a Department Representative -
for 100% US steel products where in-plant inspection has verified that the steel was melted and manufactured in the United States, only form cS-4171 is required. for products where in-plant inspection has verified minimal foreign steel in accordance withact 3 and Buyamerica, attach bills of lading or shipping documents for foreign steel, and attach form cS-4171S with supporting documentation.
r ‘Unidentified Steel’ – Steel products that do not meet the definition of ‘‘Identifiable Steel’ and do not receive in-plant inspection as
defined above. for 100% US steel products, 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. for products containing minimal foreign steel in accordance withact 3 and Buyamerica, attach bills of lading or shipping documents for foreign steel, and attach form cS-4171S with supporting documentation.
7.VenDor claSSification (cHecK one BlocK onlY) - r #1 manufacturer, fabricator, coater, precaster
listed in Bulletin # 15, or producer listed in Bulletin # 14, 41 or 42
I certify that the above statements are true and to the best of my knowledge, fairly and accurately describe the product(s) listed.
r #2 Distributor, Supplier or *private label company not listed in Bulletin # 15.
also, complete line 9
I certify that the material being supplied is one and the same as provided to us by the manufacturer listed on this document and quantities listed above are accurate.
8.name (print) : ____________________________________________ title: ____________________________________________
companY name : __________________________________________________________________________________________
SiGnatUre : ______________________________________________________ Date: __________________________________
By Responsible Company Offical
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)
CS-4171 (3-19)
certificate of compliance
www.penndot.gov
inStrUctionS
form cS-4171 is to be completed by the party that is shipping approved material to the next destination. 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#
Provide the project information where the material is being shipped. If information is unknown, leave blank. It will be completed by the Project Contractor.
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.
3.meetS Specification reQUirementS
List the specification under which the product is approved.
4.SHippeD to
List the name of the company to which the material is being shipped.
5.lot nUmBer, QUantitY, DeScription of material
List the unique Lot Number for the product, the quantity being shipped to the project or next destination, and a description of the approved material as listed in PennDOT Bulletin # 15, 14, 41, or 42.
6.cHecK tHiS BlocK if YoUr proDUct containS iron or Steel
-Check box if your product contains iron or steel, and complete the additional check boxes. If your product does not contain iron or steel, skip to Item# 7.
-Check one of the two boxes to indicate whether the product is composed of 100% US steel or whether it contains the minimum allowed foreign steel.
-Check one of the three boxes to indicate whether your product is identifiable steel, unidentified steel, or receives in-plant inspection by the Department or Department Representative.
-Be sure to provide the required supporting documentation.
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, company name, Signature, and Date
Enter the required information and sign the Certificate of Compliance form. Ink signatures or electronic signatures are acceptable.
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)
inaDDition:
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.
