CTR078009_Task_Assignment_Milling___Asphalt_Services.pdf

Exhibit

TASK ASSIGNMENT

On-call Milling & Asphalt Replacement Services Statewide

ADOT Project Manager Use

Contract Number: CTR

Requested By: Contractor:

Project Manager Phone: Contractor Phone:

Project Manager Email: Contractor Email:

Date Requested: Time Requested:

Requested Work Start Date: Requested Work Completion Date:

Time Work to Be Completed:

District Requesting Work: ADOT Unit Number:

Work Location:

Route: Direction:

Beginning M.P.: Ending M.P.:

Description of Work:

Special Instructions/Details (project access, restrictive conditions):

Contractor's Use

Contact Person: On-site Supervisor Phone:

On-site Supervisor Name: On-site Supervisor Email:

Proposed Work Start Date: Proposed Work Completion Date:

Beginning Work Hours: Ending Work Hours:

Specific Hours to be Performed:

TASK ASSIGNMENT

Traffic Control (if applicable)

Type of Closure:

Arrow Board Required? DPS Personnel Required?

Off-Duty Law Enforcement Personnel Required?

Estimated Duration of Traffic Control (Hours):

Task Assignment Due Date & Time:

Pavement Marking Quantities

Pavement Marking Line Item Unit of Measure Quantity Pavement Marking Line Item Unit Of Measure Quantity

ADOT: Contact SMCS to request form revisions.

Exhibit

Spill Kit Items

Mobilization

Contractor’s nearest yard to the initial jobsite, one way:

Task Assignment Quoted Cost

Total Cost for Quoted Line Items:

Mobilization Total Cost:

Taxes:

Task Assignment Total Quoted Cost:

Task Assignment Authorization

Project Manager Signature Date

Contractor's Signature Date

ADOT: Contact SMCS to request form revisions.