2-2026 Street Maintenance and Materials-Contract No. 2 Aggregate (MS-963).pdf

PUBLIC NOTICE

BIDS WANTED

Sealed proposals will be received online for the 2026 Street Maintenance and Materials via the PennBid Program (https://pennbid.bonfirehub.com), by the Manchester Township Board of Supervisors, York County, Pennsylvania until 10:00 AM (Prevailing Time) Thursday, April 2, 2026 for the following:

MS-944:

Contract No. 1 – Mill and remove approximately 9,130 sq. yds. bituminous material; Provide and place 8,968 sq. yds. of paving fabric; Place approximately 1,432 tons of various bituminous concrete material throughout the Township. Construct 12 ADA curb ramps and 185 L.F. of rolled concrete curb.

MS-963:

Contract No. 2 – Provide approximately 3,400 tons of various sizes of crushed aggregate Contract No. 3 – Provide approximately 2,245 tons of various bituminous Superpave materials

All materials shall conform to current PennDOT specifications.

MS-970:

Contract No. 4 – Provide approximately 32 hours of various sizes equipment rental

The bids will be publicly opened and read electronically, via PennBid’s website, at 10:00 AM (prevailing time), same date. Bid results will be available at the end of business day, same date.

A Bid Bond is not required. The successful bidder(s), when awarded a contract, shall furnish a Performance Bond and Payment Bond (with suitable surety) in the amount as specified in the Contract.

Notice is hereby given to bidders that the MS-944 Contract is subject to the provisions of the Pennsylvania Prevailing Wage Act approved August 15, 1961 (Act No. 442, P.L. 987), as amended.

Bidding documents are available to all prospective bidders online and at no cost at https://pennbid.bonfirehub.com. Manchester Township reserves the right to reject any or all proposals and to make an award in the best interest of the Township.

Manchester Township Board of Supervisors (2nd Class)

Timothy R. James, Secretary

Please Publish: Friday, March 20 and Monday, March 23, 2026

Adv.-1

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Debbie Grove Highlight

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 Manchester Township will require during the contract period.

2. The MS-944 contracts will run from May 1, 2026 to September 30, 2026.

The MS-963 and MS-970 contracts will run 365 days from May 1, 2026 to April 30, 2027.

3. Bids shall be submitted online via the PennBid Program (https://pennbid.bonfirehub.com) no later than the time and date prescribed.

Bidders shall submit the following with the respective bids:

a. Proposal and Contract (pages 1-2);

b. Special provisions to the Contract signed and dated by the Contractor (MS-944 & MS-963 only);

c. Anti-Collusion Affidavit;

d. Public Works Employment Verification Form.

4. Contractor warrants it is 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.

5. Contractor warrants that it 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 it will, in carrying out the requirements of the Contract, comply in all respects with the provisions of this Act.

6. Each Successful Bidder will furnish the following:

a. Certificate of Insurance in accordance with attached requirements;

b. Performance Bond (50%) for MS-963 and MS-970;

Performance and Payment Bonds (100%) for MS-944;

c. Workmen’s Compensation Act Affidavit (MS-944);

d. Payroll Certifications (MS-944).

7. 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 supplied daily to the Engineer or Township Representative.

8. All material suppliers shall complete and submit Form CS-4171 Certificate of Compliance in accordance with PennDOT requirements, prior to or with the first delivery of each material. Submit to the Engineer or Township representative.

9. Placement of Superpave Bituminous Material (Use Form MS-944 (7-09)) – Contract No. 1

Bidders shall submit unit prices to place Superpave materials, perform pavement milling, place pavement fabric, construct concrete ADA curb ramps and curbing, and adjust manhole frames in accordance with the requirements on Attachment 1 at various locations within the Township.

Contract award will be based upon the combined low total of Bid Items 1A through 1K.

10. Schedule of Prices-Materials:

A. Crushed Aggregate (Use Form MS-963 (11-08)) – Contract No. 2

The approximate quantity shown (3,400 Tons) is the total amount of various crushed aggregate material required. No attempt has been made to estimate the quantities of the different sizes of aggregate. Anti-skid material shall meet the requirements of Section 703.4 of PennDOT Publication 408. Bidders should submit unit prices per ton F.O.B. plant (6) and unit prices per ton F.O.B job site (7). Please indicate additional truck charge for delivery delay in excess of ½ hours. Bidders must specify location for F.O.B. Plant. Delivery time will be analyzed along with unit prices to determine which proposal is in the best interest of the municipality.

Escalator provisions will not be accepted for crushed aggregate. One Contract will be awarded to the lowest responsive bidder for Bid Items A1 through A12.

B. Bituminous Material (Use Form MS-963 (11-08)) – Contract No. 3

The approximate quantity shown (2,245 tons) is the total amount of bituminous material required. Attached hereto is a copy of PennDOT Publication 242, 2015 Edition, subject:

Aggregate Friction Requirements for Bituminous Wearing Courses. 9.5mm bituminous wearing course materials shall contain aggregate SRL, letter designation G and L, or equivalent blends. Bidders must specify location for F.O.B. Plant. Delivery time will be analyzed along with unit prices to determine which proposal is in the best interest of the municipality. Contract will be awarded to the lowest responsive bidder for total of Bid Items B1 through B3, delivered to the Job Site.

Claims for additional charges for delays requiring the material supplier to be on site for more than ½ hour will be considered only if a waiting time slip is signed by the Contractor placing the material or a Township Representative.

Due to other Township contractual obligations, the Township may use an alternate supplier if material cannot be supplied on day requested or if waiting time at the plant exceeds one hour.

Contract supplier shall be responsible for reimbursement of the cost difference between the contract unit price for the material and the alternate supplier’s unit price for the material.

An Escalator Clause will follow Pennsylvania Department of Transportation Publication 408, Section 110.04, latest edition, with the following exceptions:

a. Section 110.04.(a): Delete “100 tons of asphalt cement.” Price adjustment of bituminous material will be applicable to all quantities of asphalt cement, including asphalt cement residue contained in emulsions or cutbacks, that will be used in the bituminous materials specified or indicated for placement.

b. Section 110.04.(b).7: Delete “Cumulative price adjustment amounting to less than $500.00 will be disregarded.” Bituminous price adjustment will be calculated prior to all payments.

In accordance with the attached Manchester Township Resolution, Contract No. 3 will be subject to an Escalator Provision for liquid asphalt; therefore, the provisions of PennDOT Publication 408, Section 110.04 Price Adjustment of Asphalt Materials will apply to Contract No. 3. Bid index shall be March 2026.

11. Equipment Rental Prices (Use Form MS-970 (9-06)) – Contract No. 4

Bidders are encouraged to read carefully the terms and conditions under Section C Specifications and Sections D Certification contained on pages 1 and 2 of Form MS-970 (9-06) prior to executing the proposal.

The hourly rate bid for equipment rental for Township projects shall include all items as indicated on Page 3, no operator requested. Numerous Contracts for Equipment Rental may be awarded.

12. The project costs for the MS-944 contract has been determined to be in excess of $100,000; therefore, all Contractors and Suppliers are required to comply with the rules and conditions of the Pennsylvania Department of Labor and Industry Prevailing Minimum Wage Determination. Wage Certifications must be submitted to the Township prior to release of any payments. Pennsylvania Prevailing Wage Rates apply to all work and the Wage determination is attached herein:

MS 944 - Serial No. 26-01992 dated 03/3/2026

13. Manchester Township Board of Supervisors (2nd Class) reserves the right to reject any and all proposals. Award will be based on the best interest of the Township. The Owner fully intends to utilize the items within the bids. However, the Owner specifically reserves the right, which all bidders acknowledge by bid submission, to reduce quantities and/or projects to meet available finances.

Reduction of quantities and/or projects will not constitute grounds of additional or compensatory changes to the bidder.

END

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MS-963 (11-08) PROPOSAL AND CONTRACT FOR

EQUIPMENT AND/OR MATERIALS ONLY*

INSTRUCTIONS ON PAGE 3

A. DEPOSIT OF PROPOSALS.

1. All bids shall be submitted via the PennBid Program Manchester Township Board of Supervisors for the letting on MUNICIPALITY (Name and Type)

Thursday, April 2, 2026 ." Timothy R. James, Secretary

DATE MUNICIPAL REPRESENTATIVE

Electronic proposals will be received on or before 10:00 AM , on the above Letting Date. 3200 Farmtrail Road

TIME York, PA 17406

ADDRESS

Bids will be opened and read electronically at approximately 717-764-4646 10:00 AM , on the above Letting Date. MUNICIPAL CONTACT PHONE NUMBER

TIME

2.

3.

B. CONTRACTOR'S CERTIFICATION

Proposal of

1. It is hereby certified as follows:

b. None of the above person are employees of the municipality.

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

2.

3. Name (s) of source (s) of supply of bituminous materials.

PROPOSALS MUST BE SUBMITTED

ELECTRONICALLY VIA THE PENNBID

ELECTRONIC BID MANAGEMENT SYSTEM.

(DATE)

a. The only person (s) having an interest in this proposal is (are) [include owners of leased equipment]:

(NAME OF CONTRACTOR)

(ADDRESS)

(THIS PROPOSAL INCLUDES INSTRUCTIONS

TO BIDDERS)

Contract No. 2-Crushed Aggregate

d. All specifications referred to above have been examined by the suppliers. The supplier 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 prices listed on the Schedule of Prices (Attachment 1).

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

Supplier agrees to furnish and deliver those items for which prices have been indicated on the Schedule of Prices (Attachment

1) in accordance with the current PennDOT Specifications (Pub. 408), except bidders need not be prequalified by PennDOT (Sec. 102.01). It is understood that: (1) Bituminous materials will be purchased weight or converted gallons at 60̊ F.(2) Supplier must furnish Form CS-4171, CERTIFICATE OF COMPLIANCE and/or TR-465 DAILY BITUMINOUS MIX CERTIFICATION. (3) The Municipality reserves the right to make an award on the basis of quotations received for any item or on the basis of the aggregate total for all like items on which quotations are received.

Contract shall expire in one year from Date of Award or April 30, 2027.

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MS-963

4.

5.

SUPPLIER

BY:

TITLE TITLE

ATTESTED BY: (DATE)

Manchester Towsnhip

TITLE MUNICIPALITY

BY:

TITLE:

(SEAL) TITLE:

TOTAL AMOUNT OF CONTRACT: TITLE:

ITEMS INCLUDED IN CONTRACT:

ACCEPTED ON:

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

The supplier will comply with all requirements of the laws and implementing regulations of the Commonwealth of Pennsylvania and of 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 and, when required by law, not less than the applicable prevailing wage.

The supplier will provide the municipality with a performance bond in the amount of 50% of the contract, conditioned upon the faithful performance of the contract.

WITNESSED OR ATTESTED BY:

PLACE

SEAL

HERE

PLACE

SEAL

HERE

-2-

Delivery Date: F.O.B.

PRICE $

Net $

Rental: per (Hour, day, week, month, etc.)

PRICE $

-Trade-in $ Net $

1.

3.

4.

5.

6.

7. Contractor awarded the bid shall receive an approval copy of the contract.

8.

9. This form is PRIMARILY for use when work is performed by Local Forces.

10.

11.

2.

SCHEDULE OF PRICES

FOR EQUIPMENT AND / OR MATERIALS

EQUIPMENT Type, Make, Model, Specifications:

The proposal must be typewritten or printed.

RENTAL WITH PURCHASE OPTION (Rental to be applied to purchase price.)

OUTRIGHT PURCHASE -Trade-in

Freight On Board (FOB) asphalt is subject to the requirements of Publication 408, Section 110.04(a) Price Adjustment of Bituminous Materials.

Performance bonds are provided by only the successful bidder. Bond must be in 50% of contract

Part A of page 1 is to be completed by the municipality. Part B of page 1 is to be completed

PROPOSAL AND CONTRACT INSTRUCTIONS

If more than one proposal on any project is submitted by any individual, firm or partnership, corporation or association under the same or different names, only one lowest proposal will be considered.

Bid bonds may be waivered by municipality by crossing it out on Proposal Form 963.

by the supplier. Schedule of Prices - under equipment section the municipality must complete description, delivery date, delivery site, and check appropriate block (s) for outright purchase or rental with purchase option. Under material section all like materials must be listed together and space provided for a total of all like materials. EXAMPLE: All classes of concrete, all sizes of concrete pipe, all sizes corrugated metal pipe, all asphalt materials, etc. Columns 1, 2, 3, 4, and 5 (be sure to include delivery date) must be filled in by the municipality to insure equitable bidding. All of Columns 6, A, 7, B, 8 and C must be filled in by the supplierunless otherwise indicated. (Unit Price delivered as directed does not apply to bituminous pavements. Use form MS-944.) If more space is needed, add note at the bottom of the page: "Continued on Attachment 1 - A" and add additional sheet designated as Attachment 1-A, 1-B, etc. Repeat note for each additional sheet required. Municipality may elimiate one or two pairs of Columns 6 through C, if no bids are desired under one or two of the options.

Where Materials for a Wearing Surface Treatment are part of the contract Average Daily Traffic (ADT) Count must be included in the description.

Form MS-963 is not to be used for purchasing bituminous or other pavements in place. IF

ALTERNATE BIDS MUST BE SECURED, BOTH MS-963 AND MS-944 MUST BE USED.

An ESCALATOR CLAUSE is optional; however, it must be included in the proposal prepared by the Municipality. An escalator clause MAY NOT be inserted by the contractor.

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Attachment 1-2

1 2 3* 4** 5 6 A 7 B 8 C

ITEM

NO.

APPROX.

QUANTITY UNIT DESCRIPTION

REMARKS AND / OR

DELIVERY DATES

UNIT PRICE

FOB PLANT

TOTAL

(2 x 6)

UNIT PRICE

DELIVERED

TO JOB SITE

TOTAL

(2 x 7)

UNIT PRICE

DELIVERED

AS DIRECTED

TOTAL

(2 x 8)

1 3,400 Tons Crushed Aggregate

May 1, 2026 through April 30, 2027 use of delivery truck up to 1/2 hour on site

A1 50 Tons AASHTO #1 " $ $ $ $ N/A N/A A2 50 Tons AASHTO #3 " $ $ $ $ N/A N/A A3 500 Tons AASHTO #57 " $ $ $ $ N/A N/A A4 50 Tons AASHTO #67 " $ $ $ $ N/A N/A A5 100 Tons AASHTO #8 " $ $ $ $ N/A N/A A6 100 Tons AASHTO #10 " $ $ $ $ N/A N/A A7 100 Tons PennDOT #2RC " $ $ $ $ N/A N/A A8 1,000 Tons PennDOT #2A " $ $ $ $ N/A N/A A9 1,200 Tons AS3 (Anti-skid) " $ $ $ $ N/A N/A

A10 100 Tons R-4 Rip Rap " $ $ $ $ N/A N/A A11 100 Tons R-5 Rip Rap " $ $ $ $ N/A N/A A12 50 Tons R-6 Rip Rap " $ $ $ $ N/A N/A

A13a Single Axle $ A13b 1 Per Hour Double Axle $ A13c Tri Axle $

F.O.B. Plant Location

* GALLONS - TONS - FEET - etc. ** Includes Class - Size - Diameter

SCHEDULE OF PRICES - MATERIALS BIDDER NAME:

USE OF CUTBACK ASPHALT IS PROHIBITED

BETWEEN MAY 1st AND OCTOBER 31st EXCEPT AS

NOTED IN BULLETIN NO. 25.

ALL COLUMNS MUST BE COMPLETED UNLESS OTHERWISE

INDICATED.

***For Bituminous or other Pavements in Place, Use Form 944

CONTRACT NO. 3

Additional charge for truck for delivery requiring more than 1/2

hr. on site

4-1

(5-06)

X X

X

X

X X X

X X

X

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 Date

Company Municipality

Completion of ANTI-COLLUSION AFFIDAVIT required.

Contractor's Representative Municipality's Representative

Manchester Township

Notice to Proceed will be the date of Contract acceptance.

Final Completion Certificate & Notice of Completion required.

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

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

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

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 409 except for superpave volumetric testing.

Municipality reserves the right to limit work completed.

Taper pavement the last 3 feet to curb.

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

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

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.

Tack Coat required per Section 460, or 409 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).

Full width pavement with one pass required.

Notify the Municipality five working days prior to start of project.

Work to be completed on or before. After , liquidated damages apply at the rate of $100.00 per calander day.

Roadway to be power broomed by ( Contractor Municipality ) prior to start of project.

Excess material to be removed by ( Contractor Municipality ).

Municipality to inspect project.

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

SPECIAL PROVISIONS TO CONTRACT

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".

Traffic Control and Safety Devices to be provided by the Contractor. ( Maintenance and Protection of Traffic to comply with current MUTCD, Publication 212 and Publication 213.)

Delivery tickets for all materials.

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

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 , .

ANTI-COLLUSION AFFIDAVIT

York

Manchester Township

0841.4.01.10

N/A

County of

Company; that he is authorized to make this affidavit on behalf of said company in compliance with section 102.06 (e) of Department Specifications, Publication 408, as amended and that the said company has not, either directly or indirectly, entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of free competitive bidding in connection with such contract.

Notary Public

My Commission expires

(Contractor)

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

Engineer’s Project No. 0841.4.89.10

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

Manchester Township 3200 Farmtrail Road York, PA 17406

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Attest/Witness:

BY:

TITLE TITLE

Attest/Witness:

SURETY COMPANY

TITLE TITLE

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.

as PRINCIPAL and

KNOW ALL MEN BY THESE PRESENTS, that we

(NAME OF MUNICIPALITY)

dollars lawful money of the United States of America, to be paid to the above

WHEREAS, the above bounded Principal has entered into a contract with the above Municipality, PERFORMANCE BOND

(SURETY COMPANY)

a corporation incorporated under the law of the State of

(With Corporate Surety)

(NAME OF STATE)

bearing even date herewith, for the undertaking of certain obligations as therein set forth, specifications with the express 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 or any such alteration of forbearance being hereby waived.

as SURETY, are held and firmly bound unto

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 to and made a part thereof, and such alterations as may be made in said Specifications, as therein set forth, then this Obligation shall be void, but otherwise the same shall be and remain in full force, virtue and effect.

It is further provided that any alteration which may be made in the terms of the contract or its

Manchester Township Board of Supervisors

IN WITNESS WHEREOF, the said principal and Surety have duly executed this Bond under Seal, CONTRACTOR pursuant to due and legal action authorizing the same to be done on .

(DATE OF BOND)

PLACE

SEAL

HERE

PLACE

SEAL

HERE

-5-

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

www.pa.gov/penndot

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

www.pa.gov/penndot

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

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