1-2026 Street Maintenance – Crack Sealing (MS-944) Bid Packet.pdf

SEALED BIDS WANTED

Sealed bids for the crack sealing in various locations throughout the Borough will be received online via the PennBid Program by the Delta Borough Municipal Authority, York County, Pennsylvania until 10:00 A.M., Tuesday, February 24, 2026.

The bids will be publicly opened and read electronically, via PennBid’s website, on Tuesday, February 24, 2026, at 10:00 A.M., prevailing time. Bid results will be available end of business day, same date.

Bidding Documents for 2026 Street Maintenance – Crack Sealing (MS-944) are available online and at no cost at www.PennBid.net.

The successful bidder, when awarded a contract, shall furnish Performance and Payment Bonds (with suitable surety), as specified in the Contract.

Notice is hereby given to bidders that this project is not subject to the provisions of the Pennsylvania Prevailing Wage Act approved August 15, 1961 (Act No. 442, P.L. 987), as amended.

All proposals must be submitted online via PennBid and include documents outlined within the specifications.

Delta Borough Municipal Authority reserves the right to accept any bid or reject any or all bids.

Delta Borough Municipal Authority

Sherrie Wood

Publish Date: Thursday, February 12, 2026

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INSTRUCTIONS TO BIDDERS

AND TECHNICAL SPECIFICATIONS

1. The approximate quantities shown in the proposal (schedule of prices) are the best available estimate of the quantities of materials that Delta Borough Municipal Authority will require during the contract period.

2. MS-944: The length of the Contract will be from April 1, 2026 to August 15, 2026.

3. Bidders shall submit the following with their respective bids:

a. Proposal and Contract MS-944 (pages 1 through 2.)

b. Special provisions to Contract MS-944 (Attachment #1-A), signed and dated by the Contractor.

c. Anti-Collusion Affidavit (MS-944)

d. Public Works Employment Verification Form

4. All materials supplied under this Contract must be approved prior to delivery by submitting the job mix formula five (5) days prior to the start of construction. Form CS-4171 Certificate of Compliance, shall be completed in accordance with PennDOT requirements and supplied daily to the Engineer or Township Representative.

5. Contractor warrants that they are in compliance with the Americans with Disabilities Act (Public Law 101-336) and that it will, in carrying out requirements of this Contract; comply in all respects with the provisions of the Act and its implementing regulations.

6. Contractor warrants that he is in compliance with the United States Omnibus Transportation Employee Testing Act of 1991, and related Federal Highway Administration Regulations regarding commercial driver’s license (CDL) requirements for its employees; and that he will, in carrying out the requirements of the Contract, comply in all respects with the provisions of this Act.

7. The Successful Bidder will be required to furnish the following:

a. Performance Bond (100% of Contract Amount) for MS-944

b. Payment Bond (100% of Contract Amount) for MS-944

c. Workmen’s Compensation Affidavit

d. Certificate of Insurance, in accordance with the attached requirements

8. All work shall be in accordance with PennDOT Publication 408, Section 469 – Asphalt Joint and

Crack Sealing.

9. Schedule of Prices are listed within PennBid’s “Prepare Your Submission” tab.

10. The Contractor will furnish an itemized invoice and completed MS-NCP Notice of Completion form to the Municipality or its Engineer.

11. A Location Map is attached herein.

12. Delta Borough Municipal Authority reserves the right to reject any or all proposals and to make an award which is in the best interest of the Authority. The Owner fully intends to construct the work for which bids are solicited. However, the Owner specifically reserves the right, which all bidders acknowledge by submission of a bid, to reduce quantities and/or eliminate projects to meet available finances. Reduction of quantities or elimination of projects will not constitute grounds of additional or compensatory charges to the successful bidder.

13. A Pre-bid meeting will not be held.

MS-944

The Contract will be awarded to the lowest responsible bidder based upon the low total for Bid Item

Nos. 1 and 2.

END

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MS-944 (7-09)

TIME

Bids will be opened electronically and read at approximately , on the above Letting Date. PROPOSALS MUST BE SUBMITTED ELECTRONICALLY

TIME

complete all work within see attachment 1-A calendar days.

3 Accompanying this proposal is a certified check or bid bond in the amount of made payable to the municipality as a proposal guarantee which, it is understood, will be forfeited in case the contractor fails to comply with the requirements of the proposal.

B. PROPOSAL OF:

1 The only person interested in the proposal as principal (s) is (are):

2 None of the above persons are employees of the municipality.

3 This proposal is made without collusion with any other person, firm or corporation.

VIA THE ELECTRONIC BID MANAGEMENT SYSTEM

PENNBID (https://www.pennbid.net)

All Bids shall be submitted via the PennBid Program for the letting on

Electronic Proposals will be received on or before

DATE

on the above Letting Date.

207 Main St, Suite A, PO Box 278

10:00 AM

The contractor proposes to do and perform all work on the following project as more specifically set forth in the Schedule of Prices (Attachment), in accordance with drawings and specifications on file electronically on the PennBid Program website (www.pennbid.net), as well as the supplements and special requirements contained herein and/ or attached hereto and current PennDOT Specifications (Publication 408 and 447), except (a) bidders need not be prequalified by PennDOT (Sec.102.01), and (b) Volumetric testing of bituminous paving materials is not required (Sec. 410).

If designated as the successful bidder, the Contractor will begin work on the date specified in the notice to proceed, or as otherwise provided in the special requirements, and will

-1-

It is hereby certified as follows:

NAME / ADDRESS OF CONTRACTOR

CONTRACTORS CERTIFICATION

All plans and specifications referred to above and the site of the work have been examined by the contractor. The contractor understands that the quantities indicated herein are approximate and are subject to change as may be required; and that all work is payable on the basis of the unit price listed on the Schedule of Prices. (Attachment 1).

THIS PROPOSAL INCLUDES

INSTRUCTIONS TO BIDDERS

ADDRESS

A. DEPOSIT OF PROPOSALS.

PROPOSAL AND CONTRACT

( WHEN EXECUTED )

Delta, PA 17314

February 24, 2026

10:00 AM

Delta Borough Municipal Authority

MUNICIPALITY (NAME & TYPE)

Sherrie Wood Secretary

BY:

DATE:

TITLE:

DATE:

TITLE:

BY:

TITLE:

BY:

TITLE:

BY:

TITLE:

ATTESTED BY:

TITLE:

-2-

MUNICIPALITY

Delta Borough Municipal Authority

The Contractor will comply with all requirements of the laws and implementing regulations of the Commonwealth of Pennsylvania and the United States relating to human relations, equal opportunity and non-discrimination in employment, and will pay to workmen employed in the performance of the contract the wages to which they may be entitled.

The Contractor will provide the municipality with a performance bond, conditioned upon the faithful performance of the contract in accordance with the plans, specifications and conditions thereof, and a payment bond, conditioned on the prompt payment of all material furnished and labor supplied or performed in the prosecution of the work, in accordance with the Public Works Contractors’ Bond Law of 1967; and an affidavit accepting the provisions of the Workmen’s Compensation Act of 1915, as amended.

CONTRACTOR

DATE

ACCEPTED ON :

WITNESSED OR

ATTESTED BY:

TO BE EXECUTED ONLY IN THE EVENT THE ABOVE PROPOSAL IS ACCEPTED

SEAL

County:

Lbs.

L.S.

BID TOTAL FOR BASE BID

Must include ADT on wearing surfaces USE OF CUTBACK ASPHALT IS PROHIBITED BETWEEN MAY 1st AND OCTOBER 31st, EXCEPT AS NOTED IN BULLETIN NO. 25. FOR OPTION OR PHASE BIDS THE TOTALS FOR

EACH MUST BE INCLUDED.

* DESCRIPTION:

- 3 -

N/A

ATTACHMENT 1

TO MS - 944 ( PROPOSAL AND CONTRACT MS - 944 )

York Municipality: Delta Borough Municipal Authority

Unit 5 Price

Total

Project Number: 4061.4.01.01

DESCRIPTION OF WORK:

Dooley Road - Beginning at the intersection of Main Street to approximately 610 L.F.

west to the Borough limit

Main Street - Beginning at the intersection with Dooley Road to the intersection of Pendyrus Street

Broad Street - Beginning at the intersection with Chestnut Street to approximately 440 L.F. west of the intersection of Broad Street and Front Street to the Borough limit.

Chestnut Street - Beginning at the intersection of South Avenue to approximately 170 L.F. south of the intersection of Ridge Avenue and Chestnut Street to the Borough limit.

Ridge Avenue - Beginning at the intersection of Main Street to the intersection of Chestnut Street

College Avenue - Beginning at the intersection of Main Street to the intersection of Chestnut Street

South Avenue - Beginning at the intersection of Main Street to the intersection of Chestnut Street

LOCATION OF WORK:

TH

IS

P O

R

TI

O N

T O

B E

C O

M

PL

ET

ED

BY

T

H E

M U

N

IC

IP

AL

IT

Y

Unit

SCHEDULE OF PRICES

*Description

ESCALATOR CLAUSE:( if adopted by Municipality.)

Bid Item No. 1: Crack Sealing: Kill vegetation (by means of thermal lance or wire wheel;

minimum one week in advance of sealing); clean crack and remove all existing loose material; fill crack with rubberized joint sealing material, meeting the requirements of Penn DOT Publication 408, Section 705.4(c).

Bid Item No. 2: Street Sweeping of Main Street: Consists of sweeper/operator and disposal of debris.

All work shall be in accordance with PennDOT Publication 408, Section 469 – Asphalt Joint and Crack Sealing.

Item No.

Approximate 2 Quantities

1 7,500 Crack Sealing Street Sweeping (Main Street only)2 1

X Traffic Control and Safety Devices to be provided by the Contractor.

X Delivery tickets for all materials.

X CS-4171 Certificate of Compliance and/ or TR-465 Daily Bituminous Mixture Certification required for all materials.

X five working days prior to start of project.

X Work to be completed by August 15, 2026. After August 15, 2026, liquidated damages apply at the rate of $870.00 per calendar day.

Roadway to be power broomed by (contractor X municipality )prior to start of project.

X Excess material to be removed by (contractor X municipality .)

X Municipality to inspect project.

Need Bill of Lading for each shipment of bituminous material per Section 702.1(c) of Specifications 408.

Tack Coat required per Section 460, or 410 for superpave, of Specifications 408 and is incidental to paving item unless noted otherwise.

Prime Coat required per Section 461 of Specifications 408.

Bituminous Seal on all abutting pavement and curbs required.

Saw cut or Milled Paving Notch required and incidental to paving item unless noted otherwise.

Scratch/ Leveling Courses to be placed at the discretion of appointed inspector(s).

X Municipality reserves the right to limit work completed.

Taper pavement the last 3 feet to curb.

For FOB Source bids, hauling distance will determine selection of bid award.

Municipality reserves the right to procure material which best suits their requirements after all bids and items are reviewed.

X Incidental Preparation and clean up required. ( Project Construction Materials ) The municipality reserves the right to make an award on the basis of the aggregate total for all like items on which quotations are received.

Provide design, which meets Specifications Form 408 to the municipality 5 days prior to start of work.

X Contractor responsible for defects that occur within one year of applications.

Contractor required to review proposed project with Municipality’s Representative prior to bidding.

Oil Samples required from each distributor truck by contractor (1) one quart : A.M. & P.M. and witnessed by municipality and retained by municipality. (Oil samples must be placed in an approved type container that is compatible with oil sample.)

At least three random stone samples to be taken by contractor on project site witnessed by municipality and retained by municipality.

Complete all testing in accordance with Specification Form 408 Section 410 except for superpave volumetric testing.

X Notice to Proceed will be April 1, 2026.

X Final Completion Certificate & Notice of Completion required.

X Future award of Contract will be based on quality of work as determined by the municipality.

X Contractor, shall notify all residents of pending work to be performed.

My signature signifies that I have read and understand the above special provisions to this contract, and by being authorized by this company to act as their authorized representative, and on their behalf hereby agree to adhere to any and all of the provisions pertaining to this contract.

Date

Notify the Municipality

(5-06) SPECIAL PROVISIONS TO CONTRACT MS-944 ( Attachment 1-A )

CONTAINS IMPORTANT INFORMATION FOR THE CONTRACTOR

The Prime Contractor and subcontractors must comply with all of the following provisions that are marked with an "X".

( Maintenance and Protection of Traffic to comply with current MUTCD, Publication 212 and Publication 213.)

Full width pavement with one pass required.

Company Municipality

Contractor's Representative Municipality's Representative Date Delta Borough Municipal Authority

D-7126 ( 7-09 )

County

Municipality

Project Number

State of Fed. Project No.

( If Applicable )

The undersigned deponent deposes and says that he is the of the

BY

Sworn to and subscribed before me the undersigned notary public this day of , .

Notary Public

My Commission expires

(Contractor) competitive bidding in connection with such contract.

into any agreement, participated in any collusion, or otherwise taken any action in restraint of free

Company; that he is authorized to make this

Publication 408, as amended and that the said company has not, either directly or indirectly, entered affidavit on behalf of said company in compliance with section 102.06 (e) of Department Specifications, County of

ANTI-COLLUSION AFFIDAVIT

York

4061.4.01.01

N/A

Delta Borough Municipal Authority

Street Address 2

City State Zip Code

Doing Business As:

(if different from Legal Name)

Commonwealth of Pennsylvania Public Works Employment Verification Form

Complete and return the form to the contracting Public Body prior to the award of the contract.

Company Legal Name: ___________________________________________________________

Mailing Address: ______________________________________________________

Check one: Contractor Subcontractor

Contracting Public Body: _________________________________________________________

Contract/Project Number: ________________________________________________________

Project Description: _____________________________________________________________

Project Location: _______________________________________________________________

Date Enrolled in E-Verify (MM/DD/YYYY): ___________________________________________ As a contractor/subcontractor for the above referenced public works contract, I hereby affirm that as of today’s date, __________________________, our company is in compliance with the Public Works Employment Verification Act (‘the Act’) through utilization of the federal E-Verify Program (EVP) operated by the United States Department of Homeland Security. To the best of my/our knowledge, all employees hired are authorized to work in the United States.

It is also agreed to that all public works contractors/subcontractors will utilize the federal EVP to verify the employment eligibility of each new hire within five (5) business days of the employee start date throughout the duration of the public works contract. Documentation confirming the use of the federal EVP upon each new hire shall be maintained in the event of an investigation or audit.

I,____________________________________________, authorized representative of the company above, attest that the information contained in this verification form is true and correct and understand that the submission of false or misleading information in connection with the above verification shall be subject to sanctions provided by law.

Authorized Representative Signature Date of Signature Printed Name: _________________________________________________________________

Phone Number: ______________________ Email: ____________________________________

Street Address 1

Attachment 2

KNOW ALL PEOPLE BY THESE PRESENTS, That we, ($ ) dollars

WHEREAS, the above bounden Principal has entered into a contract with the above Municipality, bearing even date herewith, for

It is further provided that any alteration which may be made in the terms of the contractor or its specifications with the express authorizing the same to be done on .

BY

TITLE:

TITLE:

TITLE:

TITLE:

SURETY COMPANY

Attest / Witness:

a manner satisfactory to the municipality fulfill all obligations as therein set forth, then this Obligation shall be void, but otherwise the same shall be and remain in full force, virtue and effect.

approval of the Municipality or the Principal to the other, shall not in any way release the Principal and the Surety or either or any of them, their heirs, executors, administrators, successors or assigns from their liability hereunder, notice to the surety of any such alteration or forebearance being hereby waived.

IN WITNESS WHEREOF, the said Principal and Surety have duly executed this Bond under Seal, pursuant to due and legal action

(DATE OF BOND)

Attest / Witness:

CONTRACTOR

to and made a part thereof, and such alterations as may be made in said Specifications as therein provided, and shall well and truly, and in

(NAME OF STATE)

are held and firmly bound unto Delta Borough Municipal Authority in the full and just sum of

(NAME OF MUNICIPALITY)

lawful money to the United States of America, to be paid to the above Municipality or its assigns, to which payment well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.

the undertaking of certain obligations as therein set forth.

NOW, THEREFORE, the condition of this obligation is such that if the above bounden Principal, as Contractor, shall in all respects comply with and faithfully perform the terms and conditions of said Contract, including the Specifications and conditions referred

(NAME AND ADDRESS OF CONTRACTOR)

as Principal and

(SURETY COMPANY)

a corporation incorporated under the laws of the State of as Surety

MS-944S (8-24)

www.penndot.pa.gov

PERFORMANCE BOND

(With Corporate Surety)

PLACE

SEAL

HERE

PLACE

HERE

MS-944S (8-24)

KNOW ALL PEOPLE BY THESE PRESENTS, that we a corporation incorporated under the laws of the State of as SURETY, are held and firmly bond unto the , in the full and just sum of

($ ) dollars, lawful money of the United States of America, to be paid to the said or its assigns, to which payment well and truly to be made, we bind ourselves, our heirs, executors, administrators, successors and assigns, jointly and severally, firmly by these presents.

WHEREAS, the above bounden Principal has entered into a contract with the above municipality hereinafter called Obligee, bearing even date herewith, for the improvement of a certain section of highway or bridge in said Municipality consisting of:

for approximately the sum of: ($ ) dollars.

NOW, THEREFORE, the condition of this obligation is such that if the above bounden PRINCIPAL shall and will promptly pay or cause to be paid in full all sums of money which may be due by contract or otherwise, to any individual, firm, partnership, association or corporation, for all material furnished or labor supplied or performed in the prosecution of the work, whether or not the said for material or labor entered into and became component parts of the work and for rental of the equipment used and services rendered by public utilities in, or in connection with the prosecution of such work, then this obligation to be void, otherwise to remain in full force and effect.

The PRINCIPAL and SURETY, hereby, jointly and severally, agree with the Obligee herein that any individual firm, partnership, association or corporation, which has performed labor or furnished material in the prosecution of the work as provided, and any public utility which has not been paid in full therefor, may sue in assumpsit on this Payment Bond in his, their, or its own name and may prosecute the same to final for such sum or sums as may be justly due him, them or it, and PAYMENT BOND Attachment 3 as PRINCIPAL and as may be justly due him, them or it, and have execution thereon. Provided, however, that the Obligee shall not be liable for the payment of any costs of expenses of such suit.

RECOVERY by any individual, firm, partnership, association or corporation hereunder shall be subject to the provisions of the “Public Works Contractors’ Bond Law of 1967", Act No. 385, approved December 20, 1967,P.L. 869, which Act shall be incorporated herein and made a part hereof, as fully and completely as though its provisions were fully and at length herein recited.

It is further provided that any alterations which may be made in the terms of the contract or in the work to be done or materials to be furnished or labor to be supplied or performed under it or the giving by the Obligee of any extension of time for the performance of the contract or any other forebearance on the part of either the Obligee or the Principal to the other, shall not in any way release the PRINCIPAL and the SURETY or SURETIES of any such alteration, extension of forebearance being hereby waived.

IN WITNESS WHEREOF, the said PRINCIPAL and SURETY have duly executed this Bond under seal this day of ,20 .

WITNESS:

CONTRACTOR

BY:

TITLE:

SURETY COMPANY

TITLE: TITLE:

WITNESS:

TITLE:

Crack Sealing

PAYMENT BOND Attachment 3 as PRINCIPAL and

Delta Borough Municipal Authority

Delta Borough Municipal Authority

PLACE

SEAL

HERE

PLACE

HERE

Attachment 4

MS-944S (8-24)

State of

County of being duly sworn according to law deposes and says that they have accepted the provisions of the Workmen’s Compensation Act of 1915 of the Commonwealth of Pennsylvania, with has his its supplements and amendments, and have insured their liability thereunder in accordance with the terms of said its

Act with .

( TYPE OR PRINT)

BY

day of A.D. 20 .

My Commission Expires

CONTRACTOR

SIGNATURE

Sworn to and subscribed before me this

( DATE )

SIGNATURE

(SURETY COMPANY)

AFFIDAVIT RE

ACCEPTING PROVISIONS OF THE WORKMEN’S COMPENSATION ACT

he has it has

Engineer’s Project No. 4061.4.01.01

INSURANCE REQUIREMENTS FOR ALL

SUPPLIERS, CONTRACTORS AND SUBCONTRACTORS

CERTIFICATES OF INSURANCE SHALL BE FURNISHED FOR ALL COVERAGE LISTED

BELOW IN THE FOLLOWING MINIMUM AMOUNTS:

Type of Insurance Required Limits

Commercial General Liability (Per Occurrence Basis)

General Aggregate $ 1,000,000 Products & Completed Operations Aggregate 1,000,000 Person & Advertising Injury 1,000,000 Each Occurrence 1,000,000 Explosion, Collapse and Underground (XCU) 1,000,000 Fire Damage (Any one fire) 50,000 Medical Expense (Any one person) 5,000

Automobile Liability (Owned, Hired, & Non-Owned Autos

Combined Single Limit 1,000,000

Worker's Compensation and Employer's Liability (Statutory)

Each Accident 100,000 Disease - Aggregate Policy Limit 500,000 Disease - Each Employee 100,000

Deductible Limits

Deductible limits shall not exceed 5% of aggregate or combined single limits stated above.

Notice of Cancellation

All policies shall contain a provision that coverage affected will not be cancelled, materially changed or renewal refused until at least 30 days prior written notice has been given to the certificate holder.

Certificate Holder

Delta Borough Municipal Authority 207 Main St, Suite A, PO Box 278 Delta, PA 17314

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1. uCOUNTY:_________________________ uLR/SR:____________ uSEC/SEG:____________ uECMS#:____________ (u - To be completed by the party that will ship the material to the project, otherwise enter N/A.)

2. I / WE hereby certify that the material listed on line 5 was:

If a single company performs more than one operation (e.g., a company manufactures and coats guiderail), more than one box may be checked.

¨Manufactured ¨Fabricated ¨Coated ¨Precasted ¨Produced By_____________________________________________________________ ____________________________________________

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 (Company Name): __________________________________________________________ 5.

6. ¨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:

¨Product is 100% US steel. ¨Product contains minimal foreign steel in accordance with Act 3 and Buy America.

Attach Form CS-4171S with receipts or invoices.

CHECK THE BOX THAT APPLIES TO YOUR PRODUCT:

¨ ‘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.

¨ Steel 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 with Act 3 and Buy America, attach bills of lading or shipping documents for foreign steel, and attach Form CS-4171S with supporting documentation.

¨ ‘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 with Act 3 and Buy America, 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) -

¨#1 Manufacturer, Fabricator, Coater, Precaster ¨#2 Distributor, Supplier or *Private Label Company

Listed in Bulletin #15, or Producer Listed in Not Listed in Bulletin #15. Bulletin #15 or Agent listed in Bulletin #14, 41 or 42 Bulletin #14. Also, complete line 10

I certify that the above statements are true and to the best of my I certify that the material being supplied is one and the same as provided to us knowledge, fairly and accurately describe the product(s) listed. by the manufacturer listed on this document and quantities listed above are accurate.

8. By signing this document, you are certifying that this product meets the Build America, Buy America Act requirements and conforms to Section 106.11 of Publication 408.

9. NAME (print) : ____________________________________________ TITLE: ____________________________________________

COMPANY NAME : ______________________________________________ SHIPMENT/CERTIFICATION DATE: ______________

SIGNATURE : ______________________________________________________ DATE: __________________________________

10. List company that sold you the material(s) documented above: __________________________________________________________ (Complete if you checked Block # 2 on line # 7, otherwise leave blank.)

(Name of Manufacturer, Fabricator, Coater, Precaster or Producer) (Supplier Code) Must match exactly as in eCAMMS

(Company Name)

CS-4171 (2-25)

CERTIFICATE OF COMPLIANCE

By Responsible Company Offical

LOT NO. HEAT NO. QUANTITY UNIT OF

MEASURE APPROVED MATERIAL AS LISTED IN PENNDOT BULLETIN

LOT NO. HEAT NO. QUANTITY UNIT OF MEASURE APPROVED MATERIAL AS LISTED IN PennDOT BULLETIN

CS-4171 (2-25)

CERTIFICATE OF COMPLIANCE

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, enter N/A.

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, HEAT NUMBER, QUANTITY, UNIT OF MEASURE, DESCRIPTION OF MATERIAL

List the unique Lot Number and Heat Number for the product, the quantity (with unit of measure) being shipped to the project or next destination, and a description of the approved material as listed in PennDOT Bulletin #14, 15, 41, or 42.

For those items that do not pertain to the material being shipped, enter N/A.

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, Bulletin #15 items or an Agent listed in Bulletin #14, 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.)

9. CERTIFICATION REQUIREMENTS, NAME & TITLE, COMPANY NAME, SHIPMENT/CERTIFICATION DATE, SIGNATURE AND DATE

Enter the required information and sign the Certificate of Compliance form. Ink signatures or electronic signatures are acceptable.

10. COMPLETE LINE # 10 ONLY IF YOU CHECKED BLOCK # 2 ON LINE # 7, OTHERWISE LEAVE BLANK List company that sold the material to you. (Company Name)

IN ADDITION:

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.

CS-4171 (2-25)

CERTIFICATE OF COMPLIANCE

MS-NCP

MUNICIPALITY

Name of Contractor

Performance of work as specified on the above numbered contract is completed and final pavement inspection has been made by the contractor and municipality in accordance with the terms of the contract awarded.

DATE OF AWARD

Both copies of this form to be filled by the Contractor-Municipality on completion of final pavement restoration.

*DATE

for a period of one year from this date.

* The contractor is responsible for maintenance of permanent pavement repairs

By the affixing of my signature I hereby certify that final

NOTICE OF COMPLETION

IN REFERENCE TO PROJECT # 4061.4.01.01

accordance with the above contract # and is hereby accepted inspection has been made and all work has been performed in

FINAL COMPLETION CERTIFICATE

THIS PORTION TO BE COMPLETED BY MUNICIPALITY

Authorized Agent for the Municipality by the municipality as completed.

Delta Borough Municipal Authority

Signature of Contractor

Signature of Municipality

MS-NCP

Dooley Rd.

Main St.

Chestnut St.

Ridge Ave.

College Ave.

Broad St.

South Ave.