Certificate of Compliance

(Treated Timber Products)

Primary Information
Declaration

Step 1 of 2

Primary Information

Firm Name:

Furnished for TxDOT: (Check one box)

Project

Requisition

Type of Firm: (Check one box)

Treater

Supplier

TxDOT Project or Requisition Information:

Address:

Invoice Number	Quantity (Include Unit of Measure)	Material Description	Treatment Date or Lot Number	Treater (To be listed only when Supplier furnishes this certification.)

This is to certify that the materials listed above are in conformance with the governing Texas Department of Transportation specification(s). This is to also certify that representative samples of the listed materials have been tested and the test results (species of timber, treatment type, treatment retention) conform to the requirements of the applicable specifications. Copies of the test results are available for review at the Treater. Copies of other pertinent documents are available for review at the Supplier (when applicable) and at the Treater.

Step 2 of 2

Declaration

Subscribed and sworn to before me this

day of

I declare under penalty of perjury under the laws of the United States of America and the State of Texas that the foregoing is true and correct and that I am authorized to sign for the Firm listed below.

Notary Public

My Commission expires:

(Authorized Corporate Official Signature)

Date

(Print or Type Name and Title)

(Print or Type Firm Name)