CONCRETE SUMMARY - New Jersey



Date FORMTEXT ?????New Jersey Department of TransportationLocal Aid ProjectsCertificate of Compliance — State AidProject: FORMTEXT ?????Municipality: FORMTEXT ?????County: FORMTEXT ?????Contractor: FORMTEXT ?????Supplier (Name & Plant): FORMTEXT ?????Material Description: FORMTEXT ?????Material Quantity: FORMTEXT ?????Date of Shipment: FORMTEXT ?????Shipment Identifier: FORMTEXT ?????(such as label marking or seal number)Supplier CertificationThese materials conform to the project contract material requirements, and the representative samples have been tested and found to be in compliance with Standard Specification for Road and Bridge Construction 2019 subsection 106.07 CERTIFICATION OF COMPLIANCE. FORMCHECKBOX (checkbox)If this submission is for an assembly of materials, I confirm that the assembly conforms to Standard Specification for Road and Bridge Construction 2019 subsection 106.07 CERTIFICATION OF COMPLIANCE. FORMCHECKBOX (checkbox)Clearly Print/Type Name: FORMTEXT ?????Signature:Supplier’s RepresentativeLocal Public Agency Officials ApprovalApproved by: FORMTEXT ????? Clearly Print Name – County/Municipal Engineer Signature – County/Municipal Engineer(After approval submit to the Local Aid Project’s District Office) ................
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