New York State Department of Transportation
Job Stamp
CHARGES TO CONTRACTOR
|FS# |SEQ. |SPECIFICATION |DATE OF |AMOUNT |EST. | |
| |# |NUMBER |CHARGE |OF |# |DESCRIPTION |
| | | | |CHARGE | |OF CHARGE |
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[pic]
Job Stamp
SALVAGE MATERIAL TABLE
|DESCRIPTION |DISPOSITION |
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WATER MAIN IMPROVEMENT
VERIFICATION OF COMPLETION
Project Name: [Project Name]
Municipality:
Section Certified: [Project Location or Limits]
Firm Submitting: [Firm Submitting Verification]
FLUSHING
Date of Completion of Construction: [Construction Completion Date]
Date of Final Flushing: [Final Flushing Date]
DISINFECTION (AWWA C651)
Date of Disinfection: [Disinfection Date]
Date of Flushing: [Final Flushing Date]
PRESSURE TEST (AWWA C600)
Date of Pressure Test: [Pressure Test Date]
Initial Pressure: [Initial Test Pressure (p.s.i.)] p.s.i.
Pressure @ [Pressure Test Duration (hrs.)] hrs. = [Final Test Pressure (p.s.i.)] p.s.i.
CERTIFICATION
I, [Certifying Engineer’s Name], certify that the above water supply improvement was completed in conformance with approved plans, specifications and any approved amendments and was pressure tested and disinfected in accordance with the supplier of water’s specifications with the above recorded results. The water main is hereby ready for bacteriological testing.
| |,P.E. | | |
|Signature | |License No. |Date |
Dxxxxxx
LOG OF DELAYS
|DATE |DESCRIPTION OF CALL, MAIL OR ACTION |
| / / |Project Accepted |
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TABLE OF LENGTHS
| | |Length |Length |
|Location |Sta to Sta |Roadway |Bridge |
|Expressway | | | |
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|Genesee Rd | | | |
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| |SUMMARY | | |
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| |TOTAL | | |
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